Patient Interview Guide

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0179 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Patient Interview Guide Form and Instruction
1 Patient Interview Guide Attachment E_Patient Interview Guide_101818.docx Form and Instruction
Fast Track Submission_Patient Interview Guide_101818.doc Fast Track Supporting Statement IC Document
Supporting Statement_101818.doc Total Overview IC Document
Cover Page Patient Interview Guide.doc Cover Letter IC Document

Information Collection (IC) Details

IC Title:	Patient Interview Guide	Agency IC Tracking Number:

IC Status: Unchanged

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	1	Patient Interview Guide	Attachment E_Patient Interview Guide_101818.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 18	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	18	18
Annual IC Time Burden (Hours)	9	9
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Fast Track Supporting Statement	Fast Track Submission_Patient Interview Guide_101818.doc	10/29/2018
Total Overview	Supporting Statement_101818.doc	10/29/2018
Cover Letter	Cover Page Patient Interview Guide.doc	10/29/2018

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