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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0917-0036-15 OMB Form No., 0917-0036-15, IHS community Health Representative (CHR) Basic and Refresher Training	Form and Instruction	New	Available
Form 0917-0036-14 OIT Customer Satisfaction Survey - Problem Ticket, OMB No. 0917-0036-14	Form and Instruction	New	Available
Form 0917-0036-13 OIT Customer Satisfaction Survey-Service Ticket, OMB Form No. 0917-0036-13	Form and Instruction	New	Available
Form 0917-0036-12 OMB No. 0917-0036-12, Physician & Dental Customer Service Questionnaire	Form and Instruction	New	Available
Form 0917-0036-11 OMB No. 0917-0036-11, Patient Assessment	Form and Instruction	New	Available
Form 0917-0036-10 0917-0036-10 Employee Assessment	Form and Instruction	New	Available
Form 0917-0036-07 OMB Form No. 0917-0036-07 FY_Satellite Classroom Post Class Survey	Form and Instruction	New	Available
Form 0917-0036-09 OMB Form No. 0917-0036-09, iCare Nuts and Bolts Post Class Survey	Form and Instruction	New	Available
Form 0917-0036-08 OMB Form No. 0917-0036-08, iCare-CMET Post Course Survey	Form and Instruction	New	Available
Form 0917-0036-06 OMB Form No. 0917-0036-06, FY_ e Learning Post Class Survey	Form and Instruction	New	Available
Form 0917-0036-05 OMB Form No. 0917-05, FY_ Classroom Post Class Survey	Form and Instruction	New	Available
Form 0917-0036-04 IHS Customer Satisfaction Survey; EHR Survey Monkey - VIRTUAL	Form	New	Available
Form 0917-0036-002 Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: Indian Health Service (IHS) Website Customer Service Satisfaction Survey	Form and Instruction	New	Available
Form 0917-0036-03 Indian Health Service (IHS) Website Customer Service Satisfaction Survey - EHR Survey Monkey - CLASS	Form and Instruction	New	Available
Form 0917-0036-01 IHS Website Customer Satisfaction Survey Questions	Form and Instruction	New	Available
Generic_Clearance_Submission_Template.docx	Supplementary Document	Uploaded 2012-05-18	Available
Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery Part B - IHS FINAL 5-17-12.doc	Supporting Statement B	Uploaded 2012-05-17	Available
Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery Part A - IHS FINAL 5-17-12.docx	Supporting Statement A	Uploaded 2012-05-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
205084	IHS Community Health Representative Basic Training & Refresher Training	Form and Instruction	New	OMB Form No., 0917-0036-15, IHS community Health Representative (CHR) Basic and Refresher Training
204846	OIT Customer Satisfaction Survey - Problem Ticket	Form and Instruction	New	OIT Customer Satisfaction Survey - Problem Ticket, OMB No. 0917-0036-14
204735	OIT Customer Satisfaction Survey - Service Ticket	Form and Instruction	New	OIT Customer Satisfaction Survey-Service Ticket, OMB Form No. 0917-0036-13
204462	Physician/Dentist Customer Service Questionairre	Form and Instruction	New	OMB No. 0917-0036-12, Physician & Dental Customer Service Questionnaire
204388	Patient Assessment, Clinton Service Unit, IMPRESS	Form and Instruction	New	OMB No. 0917-0036-11, Patient Assessment
204346	Employee Assessment, Clinton Service Unit, IMPRESS	Form and Instruction	New	0917-0036-10 Employee Assessment
203947	Satellite Classroom Post Class Survey	Form and Instruction	New	OMB Form No. 0917-0036-07 FY_Satellite Classroom Post Class Survey
203845	iCare Nuts and Bolts Post Class Survey	Form and Instruction	New	OMB Form No. 0917-0036-09, iCare Nuts and Bolts Post Class Survey
203753	iCare - CMET Post Course Survey	Form and Instruction	New	OMB Form No. 0917-0036-08, iCare-CMET Post Course Survey
203562	eLearning Post Class Survey	Form and Instruction	New	OMB Form No. 0917-0036-06, FY_ e Learning Post Class Survey
203260	Classroom Post Class Survey	Form and Instruction	New	OMB Form No. 0917-05, FY_ Classroom Post Class Survey
203096	Website Customer Service Satisfaction Survey - EHR	Form	New	IHS Customer Satisfaction Survey; EHR Survey Monkey - VIRTUAL
203035	Website Customer Service Satisfaction Survey	Form and Instruction	New	Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: Indian Health Service (IHS) Website Customer Service Satisfaction Survey
202843	IHS Website Customer Service Satisfaction Survey - EHR Survey	Form and Instruction	New	Indian Health Service (IHS) Website Customer Service Satisfaction Survey - EHR Survey Monkey - CLASS
202645	Indian Health Service Website Customer Service Satisfaction Survey	Form and Instruction	New	IHS Website Customer Satisfaction Survey Questions

ICR Details

OMB Control No: 0917-0036	ICR Reference No: 201205-0917-002
Status: Historical Active	Previous ICR Reference No: 201201-0917-001
Agency/Subagency: HHS/IHS	Agency Tracking No:
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/25/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/18/2012
Terms of Clearance: OMB approves this collection for a period of three years. To request approval of information collections under this generic approval, the agency must do the following: 1) Unless an agency is using multiple modes of collection (e.g., paper forms and electronic submissions), provide a Generic Clearance Submission Template for each Instrument; 2) If the agency is using multiple modes of collection (e.g., paper forms and electronic submissions), the same Generic Clearance Submission Template may be used for both instruments; 3) each Generic Clearance Submission Template must be uploaded as a Supplementary document using a naming convention that allows the public to identify the associated instrument; 4) submit no more than five Generic Submission Templates with each request.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2015	36 Months From Approved
Responses	3,030	0	0
Time Burden (Hours)	1,030	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: This fast track generic collection of infomration is neccesssary to enable IHS to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improving service delivery. The information collected from our customers and stakeholders will help ensure that users have an effective, efficeint, and satisfying experience with the Agency's programs.

---

Authorizing Statute(s): US Code: 44 USC 3501 Name of Law: Paperwork Reduction Act
   EO: EO 12682 Name/Subject of EO: "Setting Customer Service Standards"
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 80542	12/22/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 1607	01/10/2012
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 15

table that charts list of burden

IC Title	Form No.	Form Name
Classroom Post Class Survey	0917-0036-05	OMB Form No. 0917-05, FY_ Classroom Post Class Survey
Employee Assessment, Clinton Service Unit, IMPRESS	0917-0036-10	0917-0036-10 Employee Assessment
IHS Community Health Representative Basic Training & Refresher Training	0917-0036-15	OMB Form No., 0917-0036-15, IHS community Health Representative (CHR) Basic and Refresher Training
IHS Website Customer Service Satisfaction Survey - EHR Survey	0917-0036-03	Indian Health Service (IHS) Website Customer Service Satisfaction Survey - EHR Survey Monkey - CLASS
Indian Health Service Website Customer Service Satisfaction Survey	0917-0036-01	IHS Website Customer Satisfaction Survey Questions
OIT Customer Satisfaction Survey - Problem Ticket	0917-0036-14	OIT Customer Satisfaction Survey - Problem Ticket, OMB No. 0917-0036-14
OIT Customer Satisfaction Survey - Service Ticket	0917-0036-13	OIT Customer Satisfaction Survey-Service Ticket, OMB Form No. 0917-0036-13
Patient Assessment, Clinton Service Unit, IMPRESS	0917-0036-11	OMB No. 0917-0036-11, Patient Assessment
Physician/Dentist Customer Service Questionairre	0917-0036-12	OMB No. 0917-0036-12, Physician & Dental Customer Service Questionnaire
Satellite Classroom Post Class Survey	0917-0036-07	OMB Form No. 0917-0036-07 FY_Satellite Classroom Post Class Survey
Website Customer Service Satisfaction Survey	0917-0036-002	Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: Indian Health Service (IHS) Website Customer Service Satisfaction Survey
Website Customer Service Satisfaction Survey - EHR	0917-0036-04	IHS Customer Satisfaction Survey; EHR Survey Monkey - VIRTUAL
eLearning Post Class Survey	0917-0036-06	OMB Form No. 0917-0036-06, FY_ e Learning Post Class Survey
iCare - CMET Post Course Survey	0917-0036-08	OMB Form No. 0917-0036-08, iCare-CMET Post Course Survey
iCare Nuts and Bolts Post Class Survey	0917-0036-09	OMB Form No. 0917-0036-09, iCare Nuts and Bolts Post Class Survey

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,030	0	0	3,030	0	0
Annual Time Burden (Hours)	1,030	0	0	1,030	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection - so there is an increase in burden.

---

Annual Cost to Federal Government: $15,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/18/2012

---