Information Collection

Indian Health Service (IHS) Patient Experience Survey

IC 208302 under ICR 201301-0917-001 · OMB 0917-0036.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0036 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OMB No. 0917-0036- Indian Health Service (IHS) Patient Experience Survey	Form and Instruction
OMB No. 0917-0036- OMB No. 0917-0036-24, IPC Patient Experience Survey OMB 0917-0036-24, IPC Patient Experience Survey Form.docx	Form and Instruction
OMB 0917-0036-24, Mini-Supporting Statement for IPC Patient Experience Survey.doc Mini-Supporting Statement for OMB 0917-0036-24, IPC Patient Experience Survey	IC Document

IC Title:

Indian Health Service (IHS) Patient Experience Survey

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OMB No. 0917-0036-24	OMB No. 0917-0036-24, IPC Patient Experience Survey	OMB 0917-0036-24, IPC Patient Experience Survey Form.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 480

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	480	480
Annual IC Time Burden (Hours)	40	40
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Mini-Supporting Statement for OMB 0917-0036-24, IPC Patient Experience Survey	OMB 0917-0036-24, Mini-Supporting Statement for IPC Patient Experience Survey.doc	08/16/2013

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