Health Information Technology Patient Satisfaction Survey (CC)

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NIH)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0648 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Health Information Technology Patient Satisfaction Survey (CC) Form and Instruction
1 Patient Portal Online Survey Screenshot Patient Portal Online Survey Screenshots 9 23 2016 w OMB control and exp date Final.docx Form and Instruction
Fast Track Request under GC 0925-0648 CC Portal Survey 9 22 2016 NP (2).doc Health Information Technology Patient Satisfaction Survey (CC) IC Document

Information Collection (IC) Details

IC Title:	Health Information Technology Patient Satisfaction Survey (CC)	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	1	Patient Portal Online Survey Screenshot	Patient Portal Online Survey Screenshots 9 23 2016 w OMB control and exp date Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Health Information Technology Patient Satisfaction Survey (CC)	Fast Track Request under GC 0925-0648 CC Portal Survey 9 22 2016 NP (2).doc	09/26/2016

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