Information Collection

Screening Questions for the DDI Patient Survey

IC 183710 under ICR 200802-0920-006 · OMB 0920-0791.

Documents and Forms

Document Name Document Type
Form No number Screening Questions for the DDI Patient Survey Form
No number DDI Patient Survey Attachment G.1 DDI Patient Survey.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Screening Questions for the DDI Patient Survey	Agency IC Tracking Number:

Is this a Common Form? No		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	No number	DDI Patient Survey	Attachment G.1 DDI Patient Survey.doc		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	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.