QI Program User Survey

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

Documents and Forms

Document Name Document Type
Form 1 QI Program User Survey Form
1 Survey Instrument – QI Software Users Draft survey instrument - QI software users 3_9_23_KHC.docx Form
1 Survey Instrument – QI Software Users Draft survey instrument - QI software users 3_9_23_KHC.docx Form
Fast Track 0935-0179 - QI Survey_feedback 1.docx Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” IC Document
Fast Track 0935-0179 - QI Survey_feedback 1.docx Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” IC Document

Information Collection (IC) Details

IC Title:	QI Program User Survey	Agency IC Tracking Number:

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	1	Survey Instrument – QI Software Users	Draft survey instrument - QI software users 3_9_23_KHC.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: Not Required	FR Citation: 85 FR 113

Number of Respondents: 400	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	400	400
Annual IC Time Burden (Hours)	67	67
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”	Fast Track 0935-0179 - QI Survey_feedback 1.docx	03/16/2023

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