Patient Survey

Demonstration of Health Literacy Universal Precautions Toolkit

Documents and Forms

Document Name Document Type
Form Form #6 Patient Survey Form and Instruction
Form #6 Patient Survey Attachment I.1 -- Patient Survey.docx Form and Instruction
Attachment I.2 -- Patient Survey Cover Memo-Tablet.docx Attachment I IC Document
Attachment I.3 -- Patient Survey Cover memo-Paper.docx Attachment I IC Document

Information Collection (IC) Details

IC Title:	Patient Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #6	Patient Survey	Attachment I.1 -- Patient Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	600	600
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment I	Attachment I.2 -- Patient Survey Cover Memo-Tablet.docx	05/30/2012
Attachment I	Attachment I.3 -- Patient Survey Cover memo-Paper.docx	05/30/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.