View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Four Corners Regional Health Center Public Health Nursing Patient Satisfaction Survey	Agency IC Tracking Number:	149

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	0917-0036-149	Four Corners Regional HC PHN Survey	Four Corners Regional HC PHN Customer Services Survey response from 4CRHC 3.27.24.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: 50	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	50	0	50	0	0	0
Annual IC Time Burden (Hours)	4	0	4	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Submission Template - FCRH Survey	Four Corners Regional HC PHN Generic Clearance Submission response from 4CRHC 3.27.24.docx	05/03/2024

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