Patient survey

Development of the Guide to Patient and Family Engagement in Health Care Quality and Safety in the Hospital Setting

Documents and Forms

Document Name Document Type
Form Form #11 Patient survey Form and Instruction
Form #11 Patient Survey Attachment Q -- Patient Survey 020411.doc Form and Instruction
Attachment R -- Invitation to Participate in Patient Survey 020411.doc Attachment R -- Invitation to Participate in Patient Survey 020411 IC Document

Information Collection (IC) Details

IC Title:	Patient survey	Agency IC Tracking Number:

Is this a Common Form? No		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	Form #11	Patient Survey	Attachment Q -- Patient Survey 020411.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 884	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	1,768	1,768
Annual IC Time Burden (Hours)	884	884
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment R -- Invitation to Participate in Patient Survey 020411	Attachment R -- Invitation to Participate in Patient Survey 020411.doc	02/10/2011

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