Information Collection

Patient Exit Survey (English, Spanish & Creole)

IC 209258 under ICR 201311-0920-005 · OMB 0920-1002.

Documents and Forms

Document Name Document Type
Patient Exit Survey (English, Spanish & Creole) Form and Instruction
Appendix 10: Patient Exit Survey (Spanish) App 10 Patient Exit Survey (Spanish).docx Form and Instruction
Appendix 11: Patient Exit Survey (Creole) App 11 Patient Exit Survey (Creole).docx Form and Instruction
Appendix 9: Patient Exit Survey (English) App 9 Patient Exit Survey (English).docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Patient Exit Survey (English, Spanish & Creole)	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Appendix 10: Patient Exit Survey (Spanish)	App 10 Patient Exit Survey (Spanish).docx	Yes	Yes	Fillable Fileable
Form and Instruction	None	Appendix 11: Patient Exit Survey (Creole)	App 11 Patient Exit Survey (Creole).docx	Yes	Yes	Fillable Fileable
Form and Instruction	None	Appendix 9: Patient Exit Survey (English)	App 9 Patient Exit Survey (English).docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,200	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
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	100	100
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.