Physician/Dentist Customer Service Questionairre

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

⚠️ Notice: This information collection may be referencing outdated material.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 0917-0036-12 Physician/Dentist Customer Service Questionairre Form and Instruction
0917-0036-12 OMB No. 0917-0036-12, Physician & Dental Customer Servic OMB No. 0917-0036-12, Physician & Dentist Customer Service Questionnaire.docx Form and Instruction
0917-0036-12, Mini Supporting Statement for Physician & Dental Customer Service Questionnaire.pdf OMB No. 0917-0036-12, Mini-Supporting Statement for Physician & Dental Customer Service Questionnaire IC Document

Information Collection (IC) Details

IC Title:	Physician/Dentist Customer Service Questionairre	Agency IC Tracking Number:

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	0917-0036-12	OMB No. 0917-0036-12, Physician & Dental Customer Service Questionnaire	OMB No. 0917-0036-12, Physician & Dentist Customer Service Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 30 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
OMB No. 0917-0036-12, Mini-Supporting Statement for Physician & Dental Customer Service Questionnaire	0917-0036-12, Mini Supporting Statement for Physician & Dental Customer Service Questionnaire.pdf	10/09/2012

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