Indian Health Service (IHS) Patient Experience Survey

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⚠️ Notice: This information collection may be referencing outdated material.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 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

Information Collection (IC) Details

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:

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 %

	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

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.