Information Collection

OMB No. 0917-0036 Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey

IC 214182 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⚠️ Notice: This information collection may be referencing outdated material.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 0917-0036 Coordinated Care Survey OMB No. 0917-0036 Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey	Form and Instruction
Form 0917-0036 Patient Registration Survey OMB No. 0917-0036 Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey	Form and Instruction
Form 0917-0036 Patient Wellness Survey OMB No. 0917-0036 Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey	Form and Instruction
0917-0036 Coordinated Care Survey Coordinated Care PT Satisfaction Survey_12_8_2014_edits.pdf	Form and Instruction
0917-0036 Patient Registration Survey Patient Registration Survey_12-8-2014.pdf	Form and Instruction
0917-0036 Patient Wellness Survey Patient Wellness Satisfaction Survey_12_8_2014_revisions.pdf	Form and Instruction
FINAL OMB No 0917-0036-Supporting Statement for IHS WRSU 12-2-14.doc : OMB No. 0917-0036- Mini-Supporting Statement Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction	IC Document

IC Title:

OMB No. 0917-0036 Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey

Agency IC Tracking Number:

0917-0036-45

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0917-0036	Coordinated Care Survey	Coordinated Care PT Satisfaction Survey_12_8_2014_edits.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	0917-0036	Patient Registration Survey	Patient Registration Survey_12-8-2014.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	0917-0036	Patient Wellness Survey	Patient Wellness Satisfaction Survey_12_8_2014_revisions.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,800

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 5 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,800	1,800
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
: OMB No. 0917-0036- Mini-Supporting Statement Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey	FINAL OMB No 0917-0036-Supporting Statement for IHS WRSU 12-2-14.doc	12/08/2014

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