Patient Services Survey

Be the Match® Patient Services Survey

Documents and Forms

Document Name Document Type
Form 1 Patient Services Survey Form and Instruction
1 OPA PSC Survey English 05122023 - OPA PSC Survey English - Burden Statement - OMB 0906-0004.docx Form and Instruction
1 OPA PSC Survey English 05122023 - OPA PSC Survey English - Burden Statement - OMB 0906-0004.docx Form and Instruction
2 OPA PSC Survey - Spanish 05122023 - OPA PSC Survey Spanish - Burden Statement - OMB 0906-0004.docx Form and Instruction
2 OPA PSC Survey - Spanish 05122023 - OPA PSC Survey Spanish - Burden Statement - OMB 0906-0004.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Patient Services Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	OPA PSC Survey English	05122023 - OPA PSC Survey English - Burden Statement - OMB 0906-0004.docx		Yes	Yes	Fillable Fileable
Form and Instruction	2	OPA PSC Survey - Spanish	05122023 - OPA PSC Survey Spanish - Burden Statement - OMB 0906-0004.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 900	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	Previously Approved
Annual Number of Responses for this IC	900	-420	1,320
Annual IC Time Burden (Hours)	153	-67	220
Annual IC Cost Burden (Dollars)	0	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.