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

Forms and Documents

Document Name	Status
Form OMB No. 0917-0036 OMB No. 0917-0036, We Care Survey, Blackfeet Community Hospital Form and Instruction	New
Form OMB No. 0917-0036 OMB No. 0917-0036 – Clinical Decision Support Usability Assessment Form and Instruction	New
Form 0917-0036 Patient Satisfaction Survey, Crow Service Unit Form and Instruction	New
Form 0917-0036 OMB No. 0917-0036, Sugar Shockers Health Campaign Survey, Catawba Service Unit Form and Instruction	New
Form 0917-0036 User satisfaction data collection for the IHS OIT NDW Form and Instruction	New
Form 0917-0036 We Care Survey, Northern Cheyenne Form and Instruction	New
Form 0917-0036 OMB No. 0917-0036 Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey Form and Instruction	New
Form 0917-0036 Catawba Service Unit Patient Satisfaction Survey Form and Instruction	New
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
Form OMB 0917-0036 We Care Survey, Fort Peck SU IHS Form and Instruction	New
Form 0917-0036 THC Dental Patient Satisfaction Survey Form and Instruction	New
Form 0917-0036 Patient Satisfaction Survey, Tohatchi Form and Instruction	New
Form 0917-0036-38 Gallup Service Unit Patient Satisfaction Survey Form and Instruction	New
Form OMB 0917-0036-0031 EHR Pharmacy Residence Informaticists Survey Form and Instruction	New
Form OMB No. 0917-0036- Providers - e-RX Deployment Form and Instruction	New
Form 0917-0036-36 Patient Satisfaction Survey, Alburquerque Service Unit Form and Instruction	New
Form 0917-0036-34 Dental Patient Satisfaction Survey Form and Instruction	New
Form 0917-0036-33 Patient Flow Time Study Form and Instruction	New
Form 0917-0036-32 Patient Satisfaction Survey, at CRHC Form and Instruction	New
Form OMB No. 0917-0036- RPMS eLearning Hands-on Customer Satisfaction Survey Form and Instruction	New
Form 0917-0036-28 RPMS Computer Based Post Class Survey Form and Instruction	New
Form 0917-0036-27 IHS Website ICD-10 Stakeholder Readiness Survey - ICD-10 Project Needs Assessment Form and Instruction	New
Form OMB No. 0917-0036- Indian Health Service (IHS) Patient Experience Survey Form and Instruction	New
Form 0917-0036-23 RPMS Annual Training Needs Assessment Form and Instruction	New
Form OMB No. 0917-0036- VPN User Survey Form and Instruction	New
Form 0917-0036-21 Portland Area Division of Environmental Health Services: Customer Service Assessment Form and Instruction	New
Form 0917-0036-18 IHS Clinical Rounds Qualitative Feedback Form and Instruction	New
Form 0917-0036-17 Community Health Representatives (CHR) National Education Training (NET) Form and Instruction	New
Form 0917-0036-20 IHS OEHE Customer Satisfaction Survey Form and Instruction	New
Form OMB No. 0917-0036- IHS Pharmacy Automation Survey 2013 Form and Instruction	New
Form OMB No. 0917-0036- Community Health Representatives (CHR) Online Diabetes Training Evaluation Form and Instruction	New
Justification for Burden Increase.docx Justification for No Material/Nonsubstantive Change	2013-01-18

IC Document Collections

IC ID	Document Title	Status
215747	OMB No. 0917-0036, We Care Survey, Blackfeet Community Hospital Form and Instruction	New
215692	OMB No. 0917-0036 – Clinical Decision Support Usability Assessment Form and Instruction	New
215641	Patient Satisfaction Survey, Crow Service Unit Form and Instruction	New
215493	OMB No. 0917-0036, Sugar Shockers Health Campaign Survey, Catawba Service Unit Form and Instruction	New
214984	User satisfaction data collection for the IHS OIT NDW Form and Instruction	New
214196	We Care Survey, Northern Cheyenne Form and Instruction	New
214182	OMB No. 0917-0036 Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey Form and Instruction	New
211841	Catawba Service Unit Patient Satisfaction Survey Form and Instruction	New
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
211657	We Care Survey, Fort Peck SU IHS Form and Instruction	New
211548	THC Dental Patient Satisfaction Survey Form and Instruction	New
211447	Patient Satisfaction Survey, Tohatchi Form and Instruction	New
211031	Gallup Service Unit Patient Satisfaction Survey Form and Instruction	New
210646	EHR Pharmacy Residence Informaticists Survey Form and Instruction	New
210541	Providers - e-RX Deployment Form and Instruction	New
210529	Patient Satisfaction Survey, Alburquerque Service Unit Form and Instruction	New
210381	Dental Patient Satisfaction Survey Form and Instruction	New
210199	Patient Flow Time Study Form and Instruction	New
210159	Patient Satisfaction Survey, at CRHC Form and Instruction	New
209925	RPMS eLearning Hands-on Customer Satisfaction Survey Form and Instruction	New
209717	RPMS Computer Based Post Class Survey Form and Instruction	New
209486	IHS Website ICD-10 Stakeholder Readiness Survey - ICD-10 Project Needs Assessment Form and Instruction	New
208302	Indian Health Service (IHS) Patient Experience Survey Form and Instruction	New
207595	RPMS Annual Training Needs Assessment Form and Instruction	New
207443	VPN User Survey Form and Instruction	New
206923	Portland Area Division of Environmental Health Services: Customer Service Assessment Form and Instruction	New
206413	IHS Clinical Rounds Qualitative Feedback Form and Instruction	New
206300	Community Health Representatives (CHR) National Education Training (NET) Form and Instruction	New
205725	IHS OEHE Customer Satisfaction Survey Form and Instruction	New
205657	IHS Pharmacy Automation Survey 2013 Form and Instruction	New
205629	Community Health Representatives (CHR) Online Diabetes Training Evaluation Form and Instruction	New

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
	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.

	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

IC Title	Form No.	Form Name
IHS Pharmacy Automation Survey 2013	OMB No. 0917-0036-19	OMB No. 0917-0036-19, IHS Pharmacy Automation Survey
OMB No. 0917-0036, We Care Survey, Blackfeet Community Hospital	OMB No. 0917-0036	We Care Survey, Blackfeet Community Hospital
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
We Care Survey, Fort Peck SU IHS	OMB 0917-0036	We Care Survey, Fort Peck SU IHS
RPMS eLearning Hands-on Customer Satisfaction Survey	OMB No. 0917-0036-30	OMB No. 0917-0036-30, RPMS eLearning Hands-on Customer Satisfaction Survey
Indian Health Service (IHS) Patient Experience Survey	OMB No. 0917-0036-24	OMB No. 0917-0036-24, IPC Patient Experience Survey
Catawba Service Unit Patient Satisfaction Survey	0917-0036	Catawaba Service Unit Patient Satisfaction 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
RPMS Annual Training Needs Assessment	0917-0036-23	OMB No. 0917-0036-23, IHS RPMS Annual Training Needs Assessment
We Care Survey, Northern Cheyenne	0917-0036	We Care Patient Satisfaction Survey for Nothern Cheyenne
RPMS Computer Based Post Class Survey	0917-0036-28	0917-0036-28, Computer Training Post Class Survey
Providers - e-RX Deployment	OMB No. 0917-0036-35	OMB No. 0917-0036-35, Providers - eRX Deployment
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
Patient Flow Time Study	0917-0036-33	Patient Flow Time Study
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
Patient Satisfaction Survey, at CRHC	0917-0036-32	Patient Satisfaction Survey, at Cheyenne River Health Center
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
VPN User Survey	OMB No. 0917-0036-22	OMB Form No. 0917-0036-22, IHS VPN User 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
OMB No. 0917-0036 – Clinical Decision Support Usability Assessment	OMB No. 0917-0036	Clinical Decision Support Usabibility Assessment - Local Clinical Reminders
Community Health Representatives (CHR) National Education Training (NET)	0917-0036-17	OMB No. 0917-0036-17, IHS CHR NET Plenary Eval Form
THC Dental Patient Satisfaction Survey	0917-0036	THC Dental Patient Satisfaction Survey
Patient Satisfaction Survey, Crow Service Unit	0917-0036	Patient Satisfaction Survey, Crow Service Unit
Patient Satisfaction Survey, Alburquerque Service Unit	0917-0036-36	OMB No. 0917-0036-36, Patient Satisfaction Survey, Albuquerque Service Unit
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
Dental Patient Satisfaction Survey	0917-0036-34	0917-0036-34, Dental Patient Satisfaction Survey
Patient Satisfaction Survey, Tohatchi	0917-0036	OMB No. 0917-0036-39, Patient Satisfaction Survey, Tohatchi
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
IHS Clinical Rounds Qualitative Feedback	0917-0036-18	0917-0036-18, IHS Clinical Rounds Qualitative Feedback Form
OMB No. 0917-0036, Sugar Shockers Health Campaign Survey, Catawba Service Unit	0917-0036	Sugar Shockers Health Campaign Survey, at Catawaba, SU

---

ICR Summary 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

---