Staff at Primary Care Practices

Patient Perpective of Delivery of Health Care Through the use of an Electronic Health Record Survey

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0361 can be found here:

Documents and Forms

Document Name Document Type
0990-PatientPerspective_App H2 Patient Recruitment Script Spanish.doc Other-Script
0990-PatientPerspective_App C Physician Practice Screener.doc Other-Screener
0990-PatientPerspective_App F4 Patient Survey Fact Sheet Spanish.doc Other-info
0990-PatientPerspective_App E2 Patient Survey Spanish.doc Other-info
0990-PatientPerspective_App F3 Patient Letter Spanish.doc Other-info
0990-PatientPerspective_App I Patient recruitment log.doc Log sheet IC Document
0990-PatientPerspective_App D3 Medical practice Followup Letter.doc 0990-PatientPerspective_App D3 Medical practice Followup Letter IC Document
0990-PatientPerspecive_App D2 Physician Practice Fact Sheet.doc 0990-PatientPerspecive_App D2 Physician Practice Fact Sheet IC Document
0990-PatientPerspective_App D1 Physician Practice Advance Letter.doc 0990-PatientPerspective_App D1 Physician Practice Advance Letter IC Document

Information Collection (IC) Details

IC Title:	Staff at Primary Care Practices	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Script	0990-PatientPerspective_App H2 Patient Recruitment Script Spanish.doc	No	No	Paper Only
Other-Screener	0990-PatientPerspective_App C Physician Practice Screener.doc	No	No	Paper Only
Other-info	0990-PatientPerspective_App F4 Patient Survey Fact Sheet Spanish.doc	No	No	Paper Only
Other-info	0990-PatientPerspective_App E2 Patient Survey Spanish.doc	No	No	Paper Only
Other-info	0990-PatientPerspective_App F3 Patient Letter Spanish.doc	No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 42	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	42	42
Annual IC Time Burden (Hours)	11	11
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Log sheet	0990-PatientPerspective_App I Patient recruitment log.doc	05/04/2010
0990-PatientPerspective_App D3 Medical practice Followup Letter	0990-PatientPerspective_App D3 Medical practice Followup Letter.doc	05/04/2010
0990-PatientPerspecive_App D2 Physician Practice Fact Sheet	0990-PatientPerspecive_App D2 Physician Practice Fact Sheet.doc	05/04/2010
0990-PatientPerspective_App D1 Physician Practice Advance Letter	0990-PatientPerspective_App D1 Physician Practice Advance Letter.doc	05/04/2010

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