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 OMB No. 0917-0036 We Care Survey, Blackfeet Community Hospital	Form and Instruction	New	Available
Form OMB No. 0917-0036 Clinical Decision Support Usabibility Assessment - Local Clinical Reminders	Form and Instruction	New	Available
Form 0917-0036 Patient Satisfaction Survey, Crow Service Unit	Form and Instruction	New	Available
Form 0917-0036 Sugar Shockers Health Campaign Survey, at Catawaba, SU	Form and Instruction	New	Available
Form 0917-0036 Indian Health Service, Office of Information Technology, National Patient Reporting System National Data Warehouse Data Collection Survey	Form and Instruction	New	Available
Form 0917-0036 We Care Patient Satisfaction Survey for Nothern Cheyenne	Form and Instruction	New	Available
Form 0917-0036 Patient Wellness Survey	Form and Instruction	New	Available
Form 0917-0036 Patient Registration Survey	Form and Instruction	New	Available
Form 0917-0036 Coordinated Care Survey	Form and Instruction	New	Available
Form 0917-0036 Catawaba Service Unit Patient Satisfaction Survey	Form and Instruction	New	Available
Form 0917-0036 OMB No. 0917-0036, Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment	Form and Instruction	New	Available
Form OMB 0917-0036 We Care Survey, Fort Peck SU IHS	Form and Instruction	New	Available
Form 0917-0036 THC Dental Patient Satisfaction Survey	Form and Instruction	New	Available
Form 0917-0036 OMB No. 0917-0036-39, Patient Satisfaction Survey, Tohatchi	Form and Instruction	New	Repair queued
Form 0917-0036-38 OMB No. 0917-0036-38, Gallup Service Unit Patient Satisfaction Survey	Form and Instruction	New	Available
Form OMB 0917-0036-0031 OMB 0917-0036-0031, EHR Pharmacy Resident Informaticist Survey	Form and Instruction	New	Available
Form OMB No. 0917-0036- OMB No. 0917-0036-35, Providers - eRX Deployment	Form and Instruction	New	Available
Form 0917-0036-36 OMB No. 0917-0036-36, Patient Satisfaction Survey, Albuquerque Service Unit	Form and Instruction	New	Available
Form 0917-0036-34 0917-0036-34, Dental Patient Satisfaction Survey	Form and Instruction	New	Available
Form 0917-0036-33 Patient Flow Time Study	Form and Instruction	New	Available
Form 0917-0036-32 Patient Satisfaction Survey, at Cheyenne River Health Center	Form and Instruction	New	Repair queued
Form OMB No. 0917-0036- OMB No. 0917-0036-30, RPMS eLearning Hands-on Customer Satisfaction Survey	Form and Instruction	New	Available
Form 0917-0036-28 0917-0036-28, Computer Training Post Class Survey	Form and Instruction	New	Available
Form 0917-0036-27 OMB No. 0917-0036-27, IHS Website ICD-10 Stakeholder Readiness Survey - ICD-10 Project Needs Assessment	Form and Instruction	New	Available
Form OMB No. 0917-0036- OMB No. 0917-0036-24, IPC Patient Experience Survey	Form and Instruction	New	Available
Form 0917-0036-23 OMB No. 0917-0036-23, IHS RPMS Annual Training Needs Assessment	Form and Instruction	New	Available
Form OMB No. 0917-0036- OMB Form No. 0917-0036-22, IHS VPN User Survey	Form and Instruction	New	Available
Form 0917-0036-21 OMB No 0917-0036-21, Portland Area Division of Environmental Health Services: Customer Services Assessment	Form and Instruction	New	Available
Form 0917-0036-18 0917-0036-18, IHS Clinical Rounds Qualitative Feedback Form	Form and Instruction	New	Available
Form 0917-0036-17 OMB No. 0917-0036-17, IHS CHR NET Plenary Eval Form	Form and Instruction	New	Available
Form 0917-0036-20 0917-0036-20, Tribal Partner Survey	Form and Instruction	New	Available
Form 0917-0036-20 0917-0036-20, Tribal Homeowner Survey	Form and Instruction	New	Available
Form 0917-0036-20 0917-0036-20, Annual Operator O & M Survey	Form and Instruction	New	Repair queued
Form 0917-0036-20 0917-0036-20, Post Construction O & M Survey	Form and Instruction	New	Available
Form OMB No. 0917-0036- OMB No. 0917-0036-19, IHS Pharmacy Automation Survey	Form and Instruction	New	Available
Form OMB No. 0917-0036- OMB No. 0917-0036-16, IHS CHR Online Diabetes Training Evaluation Form	Form and Instruction	New	Available
Justification for Burden Increase.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2013-01-18	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
215747	OMB No. 0917-0036, We Care Survey, Blackfeet Community Hospital	Form and Instruction	New	We Care Survey, Blackfeet Community Hospital
215692	OMB No. 0917-0036 – Clinical Decision Support Usability Assessment	Form and Instruction	New	Clinical Decision Support Usabibility Assessment - Local Clinical Reminders
215641	Patient Satisfaction Survey, Crow Service Unit	Form and Instruction	New	Patient Satisfaction Survey, Crow Service Unit
215493	OMB No. 0917-0036, Sugar Shockers Health Campaign Survey, Catawba Service Unit	Form and Instruction	New	Sugar Shockers Health Campaign Survey, at Catawaba, SU
214984	User satisfaction data collection for the IHS OIT NDW	Form and Instruction	New	Indian Health Service, Office of Information Technology, National Patient Reporting System National Data Warehouse Data Collection Survey
214196	We Care Survey, Northern Cheyenne	Form and Instruction	New	We Care Patient Satisfaction Survey for Nothern Cheyenne
214182	OMB No. 0917-0036 Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey	Form and Instruction	New	Patient Wellness Survey
214182	OMB No. 0917-0036 Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey	Form and Instruction	New	Patient Registration Survey
214182	OMB No. 0917-0036 Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey	Form and Instruction	New	Coordinated Care Survey
211841	Catawba Service Unit Patient Satisfaction Survey	Form and Instruction	New	Catawaba Service Unit Patient Satisfaction Survey
211814	OMB No. 0917-0036, Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment	Form and Instruction	New	OMB No. 0917-0036, Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment
211657	We Care Survey, Fort Peck SU IHS	Form and Instruction	New	We Care Survey, Fort Peck SU IHS
211548	THC Dental Patient Satisfaction Survey	Form and Instruction	New	THC Dental Patient Satisfaction Survey
211447	Patient Satisfaction Survey, Tohatchi	Form and Instruction	New	OMB No. 0917-0036-39, Patient Satisfaction Survey, Tohatchi
211031	Gallup Service Unit Patient Satisfaction Survey	Form and Instruction	New	OMB No. 0917-0036-38, Gallup Service Unit Patient Satisfaction Survey
210646	EHR Pharmacy Residence Informaticists Survey	Form and Instruction	New	OMB 0917-0036-0031, EHR Pharmacy Resident Informaticist Survey
210541	Providers - e-RX Deployment	Form and Instruction	New	OMB No. 0917-0036-35, Providers - eRX Deployment
210529	Patient Satisfaction Survey, Alburquerque Service Unit	Form and Instruction	New	OMB No. 0917-0036-36, Patient Satisfaction Survey, Albuquerque Service Unit
210381	Dental Patient Satisfaction Survey	Form and Instruction	New	0917-0036-34, Dental Patient Satisfaction Survey
210199	Patient Flow Time Study	Form and Instruction	New	Patient Flow Time Study
210159	Patient Satisfaction Survey, at CRHC	Form and Instruction	New	Patient Satisfaction Survey, at Cheyenne River Health Center
209925	RPMS eLearning Hands-on Customer Satisfaction Survey	Form and Instruction	New	OMB No. 0917-0036-30, RPMS eLearning Hands-on Customer Satisfaction Survey
209717	RPMS Computer Based Post Class Survey	Form and Instruction	New	0917-0036-28, Computer Training Post Class Survey
209486	IHS Website ICD-10 Stakeholder Readiness Survey - ICD-10 Project Needs Assessment	Form and Instruction	New	OMB No. 0917-0036-27, IHS Website ICD-10 Stakeholder Readiness Survey - ICD-10 Project Needs Assessment
208302	Indian Health Service (IHS) Patient Experience Survey	Form and Instruction	New	OMB No. 0917-0036-24, IPC Patient Experience Survey
207595	RPMS Annual Training Needs Assessment	Form and Instruction	New	OMB No. 0917-0036-23, IHS RPMS Annual Training Needs Assessment
207443	VPN User Survey	Form and Instruction	New	OMB Form No. 0917-0036-22, IHS VPN User Survey
206923	Portland Area Division of Environmental Health Services: Customer Service Assessment	Form and Instruction	New	OMB No 0917-0036-21, Portland Area Division of Environmental Health Services: Customer Services Assessment
206413	IHS Clinical Rounds Qualitative Feedback	Form and Instruction	New	0917-0036-18, IHS Clinical Rounds Qualitative Feedback Form
206300	Community Health Representatives (CHR) National Education Training (NET)	Form and Instruction	New	OMB No. 0917-0036-17, IHS CHR NET Plenary Eval Form
205725	IHS OEHE Customer Satisfaction Survey	Form and Instruction	New	0917-0036-20, Tribal Partner Survey
205725	IHS OEHE Customer Satisfaction Survey	Form and Instruction	New	0917-0036-20, Tribal Homeowner Survey
205725	IHS OEHE Customer Satisfaction Survey	Form and Instruction	New	0917-0036-20, Annual Operator O & M Survey
205725	IHS OEHE Customer Satisfaction Survey	Form and Instruction	New	0917-0036-20, Post Construction O & M Survey
205657	IHS Pharmacy Automation Survey 2013	Form and Instruction	New	OMB No. 0917-0036-19, IHS Pharmacy Automation Survey
205629	Community Health Representatives (CHR) Online Diabetes Training Evaluation	Form and Instruction	New	OMB No. 0917-0036-16, IHS CHR Online Diabetes Training Evaluation Form

ICR Details

OMB Control No: 0917-0036	ICR Reference No: 201301-0917-001
Status: Historical Active	Previous ICR Reference No: 201205-0917-002
Agency/Subagency: HHS/IHS	Agency Tracking No:
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/31/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/18/2013
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	05/31/2015	05/31/2015
Responses	105,000	0	3,030
Time Burden (Hours)	40,000	0	1,030
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

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 31

table that charts list of burden

IC Title	Form No.	Form Name
Catawba Service Unit Patient Satisfaction Survey	0917-0036	Catawaba Service Unit Patient Satisfaction Survey
Community Health Representatives (CHR) National Education Training (NET)	0917-0036-17	OMB No. 0917-0036-17, IHS CHR NET Plenary Eval Form
Community Health Representatives (CHR) Online Diabetes Training Evaluation	OMB No. 0917-0036-16	OMB No. 0917-0036-16, IHS CHR Online Diabetes Training Evaluation Form
Dental Patient Satisfaction Survey	0917-0036-34	0917-0036-34, Dental Patient Satisfaction Survey
EHR Pharmacy Residence Informaticists Survey	OMB 0917-0036-0031	OMB 0917-0036-0031, EHR Pharmacy Resident Informaticist Survey
Gallup Service Unit Patient Satisfaction Survey	0917-0036-38	OMB No. 0917-0036-38, Gallup Service Unit Patient Satisfaction Survey
IHS Clinical Rounds Qualitative Feedback	0917-0036-18	0917-0036-18, IHS Clinical Rounds Qualitative Feedback Form
IHS OEHE Customer Satisfaction Survey	0917-0036-20, 0917-0036-20, 0917-0036-20, 0917-0036-20	0917-0036-20, Post Construction O & M Survey ,   0917-0036-20, Annual Operator O & M Survey ,   0917-0036-20, Tribal Homeowner Survey ,   0917-0036-20, Tribal Partner Survey
IHS Pharmacy Automation Survey 2013	OMB No. 0917-0036-19	OMB No. 0917-0036-19, IHS Pharmacy Automation Survey
IHS Website ICD-10 Stakeholder Readiness Survey - ICD-10 Project Needs Assessment	0917-0036-27	OMB No. 0917-0036-27, IHS Website ICD-10 Stakeholder Readiness Survey - ICD-10 Project Needs Assessment
Indian Health Service (IHS) Patient Experience Survey	OMB No. 0917-0036-24	OMB No. 0917-0036-24, IPC Patient Experience Survey
OMB No. 0917-0036 Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey	0917-0036, 0917-0036, 0917-0036	Coordinated Care Survey ,   Patient Registration Survey ,   Patient Wellness Survey
OMB No. 0917-0036 – Clinical Decision Support Usability Assessment	OMB No. 0917-0036	Clinical Decision Support Usabibility Assessment - Local Clinical Reminders
OMB No. 0917-0036, Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment	0917-0036	OMB No. 0917-0036, Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment
OMB No. 0917-0036, Sugar Shockers Health Campaign Survey, Catawba Service Unit	0917-0036	Sugar Shockers Health Campaign Survey, at Catawaba, SU
OMB No. 0917-0036, We Care Survey, Blackfeet Community Hospital	OMB No. 0917-0036	We Care Survey, Blackfeet Community Hospital
Patient Flow Time Study	0917-0036-33	Patient Flow Time Study
Patient Satisfaction Survey, Alburquerque Service Unit	0917-0036-36	OMB No. 0917-0036-36, Patient Satisfaction Survey, Albuquerque Service Unit
Patient Satisfaction Survey, Crow Service Unit	0917-0036	Patient Satisfaction Survey, Crow Service Unit
Patient Satisfaction Survey, Tohatchi	0917-0036	OMB No. 0917-0036-39, Patient Satisfaction Survey, Tohatchi
Patient Satisfaction Survey, at CRHC	0917-0036-32	Patient Satisfaction Survey, at Cheyenne River Health Center
Portland Area Division of Environmental Health Services: Customer Service Assessment	0917-0036-21	OMB No 0917-0036-21, Portland Area Division of Environmental Health Services: Customer Services Assessment
Providers - e-RX Deployment	OMB No. 0917-0036-35	OMB No. 0917-0036-35, Providers - eRX Deployment
RPMS Annual Training Needs Assessment	0917-0036-23	OMB No. 0917-0036-23, IHS RPMS Annual Training Needs Assessment
RPMS Computer Based Post Class Survey	0917-0036-28	0917-0036-28, Computer Training Post Class Survey
RPMS eLearning Hands-on Customer Satisfaction Survey	OMB No. 0917-0036-30	OMB No. 0917-0036-30, RPMS eLearning Hands-on Customer Satisfaction Survey
THC Dental Patient Satisfaction Survey	0917-0036	THC Dental Patient Satisfaction Survey
User satisfaction data collection for the IHS OIT NDW	0917-0036	Indian Health Service, Office of Information Technology, National Patient Reporting System National Data Warehouse Data Collection Survey
VPN User Survey	OMB No. 0917-0036-22	OMB Form No. 0917-0036-22, IHS VPN User Survey
We Care Survey, Fort Peck SU IHS	OMB 0917-0036	We Care Survey, Fort Peck SU IHS
We Care Survey, Northern Cheyenne	0917-0036	We Care Patient Satisfaction Survey for Nothern Cheyenne

---

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	105,000	3,030	0	0	101,970	0
Annual Time Burden (Hours)	40,000	1,030	0	0	38,970	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

---

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: 01/18/2013

---