2022 Patient Perception Inpatient Surveys (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⚠️ Notice: This information collection may be referencing outdated material.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 2022 Patient Perception Inpatient Surveys (CC) Form
1 Adult Inpatient Survey Revised with Discharge Question Adult Inpatient Survey Revised w Discharge Questions.docx Form
2 Pediatric Inpatient Survey Pediatric Inpatient Survey Updated Screen Shots.docx Form
3 Adult and Pediatric Surgery-Procedure Survey Adult and Pediatric Surgery-Procedure Survey Updated Screen Shots.docx Form
01 Fast Track Request Patient Perception Inpatient Survey Non Behavioral Health FINAL.docx fast track for 2022 Patient Perception Inpatient Survey IC Document
Introductory Email-Login-Welcome Message.docx Introductory email IC Document

Information Collection (IC) Details

IC Title:	2022 Patient Perception Inpatient Surveys (CC)	Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Adult Inpatient Survey Revised with Discharge Question	Adult Inpatient Survey Revised w Discharge Questions.docx	Yes	Yes	Fillable Fileable
Form	2	Pediatric Inpatient Survey	Pediatric Inpatient Survey Updated Screen Shots.docx	Yes	Yes	Fillable Fileable
Form	3	Adult and Pediatric Surgery-Procedure Survey	Adult and Pediatric Surgery-Procedure Survey Updated Screen Shots.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,900	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	39,200	39,200
Annual IC Time Burden (Hours)	3,267	3,267
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
fast track for 2022 Patient Perception Inpatient Survey	01 Fast Track Request Patient Perception Inpatient Survey Non Behavioral Health FINAL.docx	02/03/2022
Introductory email	Introductory Email-Login-Welcome Message.docx	02/03/2022

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