View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Patient Key Informant Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division	Agency IC Tracking Number:

IC Status: Removed

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 Key Informants	Customer Satisfaction Survey_Patient FINAL.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	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: 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	0	0	-40	0	0	40
Annual IC Time Burden (Hours)	0	0	-10	0	0	10
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Cover Letter	OMB Cover Letter_patientKI.doc	11/07/2017
Supporting Statement	Generic Clearance Submission Patient Questions FINAL.doc	11/07/2017

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