Client Satisfaction Survey

Frontier Community Healthcare Network Coordination Grant

Documents and Forms

Document Name Document Type
Form 1 Client Satisfaction Survey Form and Instruction
1 Client Satisfaction Survey ClientSatisfactionSurvey_OMBClearance_10232013.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Client Satisfaction Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	Client Satisfaction Survey	ClientSatisfactionSurvey_OMBClearance_10232013.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 85	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	85	85
Annual IC Time Burden (Hours)	14	14
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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