Information Collection

PT/OT (Therapy Department) - Provision of Care Survey

IC 221047 under ICR 201504-0917-007 · OMB 0917-0036.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0036 can be found here:

Documents and Forms

Document Name Document Type
Form 0917-0036 PT/OT (Therapy Department) - Provision of Care Survey Form and Instruction
0917-0036 PT/OT (Therapy Department) - Provision of Care Survey OMB 0917-0036-60 Therapy Patient Experience Survey Form, Joshua Mistic, 04-12-2016.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	PT/OT (Therapy Department) - Provision of Care Survey	Agency IC Tracking Number:	60

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 and Instruction	0917-0036	PT/OT (Therapy Department) - Provision of Care Survey	OMB 0917-0036-60 Therapy Patient Experience Survey Form, Joshua Mistic, 04-12-2016.docx		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 350	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	350	350
Annual IC Time Burden (Hours)	18	18
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.