Patient Perception Survey (CC)

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NIH)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0648 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Patient Perception Survey (CC) Form
1 NIH Inpatient Mock-up - NRC Health NIHAIP Survey Mock-up - NRC Health.pdf Form
2 NIH Outpatient Mock-up -NRC Health NIHAOP Survey Mock-up - NRC Health.pdf Form
Fast Track Request under GC 0925-0648 CC Patient Perception Surveys.doc Patient Perception Survey fast track IC Document

Information Collection (IC) Details

IC Title:	Patient Perception Survey (CC)	Agency IC Tracking Number:

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	1	NIH Inpatient Mock-up - NRC Health	NIHAIP Survey Mock-up - NRC Health.pdf		No		Paper Only
Form	2	NIH Outpatient Mock-up -NRC Health	NIHAOP Survey Mock-up - NRC Health.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	7,500	7,500
Annual IC Time Burden (Hours)	3,750	3,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Patient Perception Survey fast track	Fast Track Request under GC 0925-0648 CC Patient Perception Surveys.doc	02/14/2018

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