View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Patient Satisfaction Survey - Crownpoint Service Unit	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 and Instruction	9017-0036	Patient Survey	Patient Satisfaction Survey FORM FY2022 Crownpoint Service Unit.docx		No		Printable 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: 500	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	500	0	500	0	0	0
Annual IC Time Burden (Hours)	83	0	83	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Patient Survey Crownpoint Template	Generic Clearance Submission Template - Patient Survey - Crownpoint.pdf	11/03/2021

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