Information Collection

DDI Patient Survey

IC 183711 under ICR 200802-0920-006 · OMB 0920-0791.

Documents and Forms

Document Name Document Type
Form No number DDI Patient Survey Form
No number DDI Patient Survey Attachment G.1 DDI Patient Survey.doc Form
Attachment G.2 Stated Preferences Module.doc Attachment G IC Document
Attachment G.4 Patient Consent.doc Attachment G IC Document
Attachment G.5 FAQ for the DDI Patient Survey.doc Attachment G IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	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: 600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 25 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment G	Attachment G.2 Stated Preferences Module.doc	01/16/2008
Attachment G	Attachment G.4 Patient Consent.doc	01/16/2008
Attachment G	Attachment G.5 FAQ for the DDI Patient Survey.doc	01/16/2008

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