OMB No. 0917-0036 Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction 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⚠️ Notice: This information collection may be referencing outdated material.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 0917-0036 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

Information Collection (IC) Details

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:

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 %

	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

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.