View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	Agency IC Tracking Number:	95

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	1	Behavioral Health Patient Satisfaction Survey	Behavioral Health Patient Satisfaction Survey 3-21.docx		No		Paper Only
Form and Instruction	2	Dental Patient Satisfaction Survey	Dental Patient Satisfaction Survey 3-21.docx		No		Paper Only
Form and Instruction	3	Laboratory Patient Satisfaction Survey	Laboratory Patient Satisfaction Survey 3-21.docx		No		Paper Only
Form and Instruction	4	Nutrition Services Patient Satisfaction Survey	Nutrition Services Patient Satisfaction Survey 3-21.docx		No		Paper Only
Form and Instruction	5	Optometry Patient Satisfaction Survey	Optometry Patient Satisfaction Survey 3-21.docx		No		Paper Only
Form and Instruction	6	Pharmacy Patient Satisfaction Survey	Pharmacy Patient Satisfaction Survey 3-21.doc.docx		No		Paper Only
Form and Instruction	7	Physcial Therapy Patient Satisfaction Survey	Physical Therapy Patient Satisfaction Survey 3-21.doc.docx		No		Paper Only
Form and Instruction	8	Radiology Patient Satisfaction Survey	Radiology Patient Satisfaction Survey 3-21.doc.docx		No		Paper Only

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: 960	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	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	960	0	960	0	0	0
Annual IC Time Burden (Hours)	80	0	80	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Generic Clearance Submission Template	Generic Clearance Submission Template - WWKMHCC 2-21.docx	04/23/2021

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