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Patient Survey
Understanding Health System Approaches to Chronic Pain Management
OMB: 0920-1374
IC ID: 251282
OMB.report
HHS/CDC
OMB 0920-1374
ICR 202201-0920-014
IC 251282
( )
Documents and Forms
Document Name
Document Type
Form 0920-
Patient Survey
Form and Instruction
0920- Patient Survey
Att. B Patient Survey.docx
Form and Instruction
Att. J.1 Patient Survey Screen Shot.pdf
Att J1_Screenshots_Patient Survey
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Patient Survey
Agency IC Tracking Number:
0920-21IE
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
0920-
Patient Survey
Att. B Patient Survey.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
667
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
667
0
667
0
0
0
Annual IC Time Burden (Hours)
111
0
111
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Att J1_Screenshots_Patient Survey
Att. J.1 Patient Survey Screen Shot.pdf
01/26/2022
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.