Patient Key Informant Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0179 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Patient Key Informant Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division Form and Instruction
1 Patient Key Informants Customer Satisfaction Survey_Patient FINAL.docx Form and Instruction
OMB Cover Letter_patientKI.doc Cover Letter IC Document
Generic Clearance Submission Patient Questions FINAL.doc Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	Patient Key Informant Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division	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 Key Informants	Customer Satisfaction Survey_Patient FINAL.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Cover Letter	OMB Cover Letter_patientKI.doc	11/07/2017
Supporting Statement	Generic Clearance Submission Patient Questions FINAL.doc	11/07/2017

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