OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

ICR 201301-0917-001 · OMB 0917-0036 · Public filing

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
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 IDCollectionTypeStatusForm
215747 OMB No. 0917-0036, We Care Survey, Blackfeet Community Hospital Form and Instruction NewWe Care Survey, Blackfeet Community Hospital
215692 OMB No. 0917-0036 – Clinical Decision Support Usability Assessment Form and Instruction NewClinical Decision Support Usabibility Assessment - Local Clinical Reminders
215641 Patient Satisfaction Survey, Crow Service Unit Form and Instruction NewPatient Satisfaction Survey, Crow Service Unit
215493 OMB No. 0917-0036, Sugar Shockers Health Campaign Survey, Catawba Service Unit Form and Instruction NewSugar Shockers Health Campaign Survey, at Catawaba, SU
214984 User satisfaction data collection for the IHS OIT NDW Form and Instruction NewIndian 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 NewWe 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 NewPatient Wellness Survey
214182 OMB No. 0917-0036 Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey Form and Instruction NewPatient Registration Survey
214182 OMB No. 0917-0036 Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey Form and Instruction NewCoordinated Care Survey
211841 Catawba Service Unit Patient Satisfaction Survey Form and Instruction NewCatawaba 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 NewOMB 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 NewWe Care Survey, Fort Peck SU IHS
211548 THC Dental Patient Satisfaction Survey Form and Instruction NewTHC Dental Patient Satisfaction Survey
211447 Patient Satisfaction Survey, Tohatchi Form and Instruction NewOMB No. 0917-0036-39, Patient Satisfaction Survey, Tohatchi
211031 Gallup Service Unit Patient Satisfaction Survey Form and Instruction NewOMB No. 0917-0036-38, Gallup Service Unit Patient Satisfaction Survey
210646 EHR Pharmacy Residence Informaticists Survey Form and Instruction NewOMB 0917-0036-0031, EHR Pharmacy Resident Informaticist Survey
210541 Providers - e-RX Deployment Form and Instruction NewOMB No. 0917-0036-35, Providers - eRX Deployment
210529 Patient Satisfaction Survey, Alburquerque Service Unit Form and Instruction NewOMB No. 0917-0036-36, Patient Satisfaction Survey, Albuquerque Service Unit
210381 Dental Patient Satisfaction Survey Form and Instruction New0917-0036-34, Dental Patient Satisfaction Survey
210199 Patient Flow Time Study Form and Instruction NewPatient Flow Time Study
210159 Patient Satisfaction Survey, at CRHC Form and Instruction NewPatient Satisfaction Survey, at Cheyenne River Health Center
209925 RPMS eLearning Hands-on Customer Satisfaction Survey Form and Instruction NewOMB No. 0917-0036-30, RPMS eLearning Hands-on Customer Satisfaction Survey
209717 RPMS Computer Based Post Class Survey Form and Instruction New0917-0036-28, Computer Training Post Class Survey
209486 IHS Website ICD-10 Stakeholder Readiness Survey - ICD-10 Project Needs Assessment Form and Instruction NewOMB 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 NewOMB No. 0917-0036-24, IPC Patient Experience Survey
207595 RPMS Annual Training Needs Assessment Form and Instruction NewOMB No. 0917-0036-23, IHS RPMS Annual Training Needs Assessment
207443 VPN User Survey Form and Instruction NewOMB Form No. 0917-0036-22, IHS VPN User Survey
206923 Portland Area Division of Environmental Health Services: Customer Service Assessment Form and Instruction NewOMB No 0917-0036-21, Portland Area Division of Environmental Health Services: Customer Services Assessment
206413 IHS Clinical Rounds Qualitative Feedback Form and Instruction New0917-0036-18, IHS Clinical Rounds Qualitative Feedback Form
206300 Community Health Representatives (CHR) National Education Training (NET) Form and Instruction NewOMB No. 0917-0036-17, IHS CHR NET Plenary Eval Form
205725 IHS OEHE Customer Satisfaction Survey Form and Instruction New0917-0036-20, Tribal Partner Survey
205725 IHS OEHE Customer Satisfaction Survey Form and Instruction New0917-0036-20, Tribal Homeowner Survey
205725 IHS OEHE Customer Satisfaction Survey Form and Instruction New0917-0036-20, Annual Operator O & M Survey
205725 IHS OEHE Customer Satisfaction Survey Form and Instruction New0917-0036-20, Post Construction O & M Survey
205657 IHS Pharmacy Automation Survey 2013 Form and Instruction NewOMB No. 0917-0036-19, IHS Pharmacy Automation Survey
205629 Community Health Representatives (CHR) Online Diabetes Training Evaluation Form and Instruction NewOMB No. 0917-0036-16, IHS CHR Online Diabetes Training Evaluation Form

ICR Details

Record metadata
OMB Control No0917-0036