Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: IHS Customer Service Satisfaction and Similar Surveys

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0917-0036-58-3 CSU Health Promotion survey	Form and Instruction	New	Available
Form 0917-0036 Evaluation Survey	Form and Instruction	New	Repair queued
Form 0917-0036 Hand Washing Survey	Form and Instruction	New	Available
Form 0917-0036 Fort Washakie Medical Home Patient Feedback	Form and Instruction	New	Available
Form 0917-0036-12 Patient Satisfaction Survey for the White Earth Optometry Dept.	Form and Instruction	New	Available
Form 0917-0036-23 Training Needs Survey	Form and Instruction	New	Available
Form 0917-0036 RDN Services Survey	Form	New	Available
Form 0917-0036 Community Nutrition Gardening Survey	Form	New	Available
Form 0917-0036 WebTMA Survey	Form and Instruction	New	Available
Form 0917-0036 Telebehavioral Health Patient Satisfaction Survey	Form	New	Available
Form 0917-0036 Public Health Nursing (PHN) Data Mart Survey Questions	Form and Instruction	New	Available
Form 0917-0036 Patient Experience of Care Survey	Form and Instruction	New	Available
Form IHS Web Services C IHS Web Services Customer Feedback	Form	New	Available
Form 0917-0036 PT/OT (Therapy Department) - Provision of Care Survey	Form and Instruction	New	Available
Form 0917-0036 IHS CHR Basic Online Training Evaluation	Form and Instruction	New	Available
Form 0917-0036 Public Health Nursing - for Patient	Form and Instruction	New	Available
Form 0917-0036 Public Health Nursing - for Patient Care Giver - Survey	Form and Instruction	New	Available
Form 0917-0036 Native Medicine Survey	Form and Instruction	New	Available
Form 0917-0036 Health Promotion Survey	Form and Instruction	New	Available
Form 0917-0036 Diabetes Survey	Form and Instruction	New	Repair queued
Form 0917-0036 Community Nutrition Survey	Form and Instruction	New	Available
Form 0917-0036 Adolescent School Health	Form and Instruction	New	Available
Form 0917-0036 Wellness Center Survey	Form and Instruction	New	Available
Form 0917-0036 Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit CSU)	Form and Instruction	New	Available
Form 0917-0036 Obstetrical Care Unit (OCU) Patient Experience Suvey, Chinle Service Unit (CSU)	Form and Instruction	New	Available
Form 0917-0036 Special Care Unit (SCU) Patient Experience Survey	Form and Instruction	New	Available
Form 0917-0036 Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit	Form and Instruction	New	Available
Form 0917-0036 CSU Employee Survey 2015	Form and Instruction	New	Available
Form 0917-0036 We Care Survey, Fort Peck Service Unit, Indian Health Service	Form and Instruction	New	Available
Form 0917-0036 Clinical Decision Support Usability Assessment	Form and Instruction	New	Available
Form 0917-0036 Patient Satisfaction Survey, Crow Service Unit	Form and Instruction	New	Available
Form 0917-0036 Sugar Shockers Health Campaign Survey, Catawba Service Unit	Form and Instruction	New	Available
Form 0917-0036 Indian Health Service, Office of Information Technology, National Patient Reporting System National Data Warehouse Data Collection Survey	Form and Instruction	New	Available
Form 0917-0036 We Care Patient Satisfaction Survey for Northern Cheyenne	Form and Instruction	New	Available
Form 0917-0036 We Care Survey, Blackfeet Community Hospital.	Form and Instruction	New	Repair queued
Form 0917-0036 Patient Wellness Survey	Form and Instruction	New	Repair queued
Form 0917-0036 Patient Registration Suvey	Form and Instruction	New	Available
Form 0917-0036 Coordinated Care Survey	Form and Instruction	New	Available
Form 0917-0036 Catawba Service Unit Patient Satisfaction Survey	Form and Instruction	New	Available
Form 0917-0036 Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment	Form and Instruction	New	Available
Form 0917-0036 We Care Survey, Fort Peck Service Unit Indian Health Service	Form and Instruction	New	Available
Form 0917-0036 THC Dental Patient Satisfaction Survey	Form and Instruction	New	Available
Form 0917-0036 Patient Satisfaction Survey, Tohatchi	Form and Instruction	New	Repair queued
Form 0917-0036 Gallup Service Unit Patient Satisfaction Survey	Form and Instruction	New	Available
Form 0917-0036 Patient Satisfaction Survey, Alburquerque Service Unit	Form and Instruction	New	Available
Form 0917-0036 Providers - e-RX Deployment Survey	Form and Instruction	New	Available
Form 0917-0036 White Earth Dental Clinic Patient Satisfaction Survey	Form and Instruction	New	Available
Form 0917-0036 Patient Flow Time Study	Form and Instruction	New	Repair queued
Form 0917-0036 Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)	Form and Instruction	New	Available
Form 0917-0036 EHR Pharmacy Residence Informaticists Survey	Form and Instruction	New	Available
Form 0917-0036 eLearning Hands-on Customer Satisfaction survey	Form and Instruction	New	Available
Form 0917-0036 Computer Based Training (CBT)Post Class Survey	Form and Instruction	New	Available
Form 0917-0036 IHS Website ICD-10 Stakeholder Readiness Survey – ICD-10 Project Needs Assessment	Form and Instruction	New	Available
Form 0917-0036 IHS Patient Experience Survey	Form and Instruction	New	Available
Form 0917-0036 IHS RPMS Annual Training Needs Assessment Survey	Form and Instruction	New	Available
Form 0917-0036 VPN User Survey	Form and Instruction	New	Available
Form 0917-0036 Portland Area Division of Environment Health Services: Customer Service Assessment.	Form and Instruction	New	Available
Form 0917-0036 Tribal Partner Survey	Form and Instruction	New	Repair queued
Form 0917-0036 Tribal Homeowner Survey	Form and Instruction	New	Available
Form 0917-0036 Post-Construction O & M Survey	Form and Instruction	New	Available
Form 0917-0036 Annual Operator O & M Survey	Form and Instruction	New	Available
Form 0917-0036 IHS Pharmacy Automation 2015 Survey	Form and Instruction	New	Repair queued
Form 0917-0036 Indian Health Service (IHS) Clinical Rounds Qualitative Feedback	Form and Instruction	New	Available
Form 0917-0036 IHS CHR NET Plenary Evaluation Form	Form and Instruction	New	Available
Form 0917-0036 Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation	Form and Instruction	New	Available
Form 0917-0036 IHS Community Health Representative Basic Training & Refresher Course Training form	Form and Instruction	New	Available
Form 0917-0036 OIT Customer Satisfaction Survey – Problem Ticket (screen shot)	Form and Instruction	New	Available
Form 0917-0036 OIT Customer Satisfaction Survey – Problem Ticket	Form and Instruction	New	Available
Form 0917-0036 OIT Customer Satisfaction Survey-Service Ticket (screen shot)	Form and Instruction	New	Available
Form 0917-0036 OIT Customer Satisfaction Survey-Service Ticket	Form and Instruction	New	Repair queued
Form 0917-0036 Physician/Dentist Customer Service Questionnaire	Form and Instruction	New	Available
Form 0917-0036 Patient Assessment –Clinton Service Unit - IMPRESS	Form and Instruction	New	Repair queued
Form 0917-0036 Employee Assessment- Clinton Service Unit - IMPRESS	Form and Instruction	New	Available
Form 0917-0036 FY___Satellite Classroom with Areas Post Class Survey	Form and Instruction	New	Available
Form 0917-0036 Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey	Form and Instruction	New	Available
Form 0917-0036 Indian Health Service (IHS) FY_ eLearning Post Class Survey	Form and Instruction	New	Repair queued
Form 0917-0036 Indian Health Service (IHS) FY_ Classroom Post Class Survey	Form and Instruction	New	Available
Form 0917-0036 IHS Website Customer Satisfaction Survey – EHR Survey Monkey – VIRTUAL	Form and Instruction	New	Available
Form 0917-0036 IHS Website Customer Satisfaction Survey – EHR Survey Monkey – Classroom Form	Form and Instruction	New	Available
Form 0917-0036 IHS Website Customer Satisfaction Survey - First Page	Form and Instruction	New	Available
Form 0917-0036 IHS Website Feedback Form	Form and Instruction	New	Available
FR Pubication 05-12-15.pdf	Supplementary Document	Uploaded 2015-05-13	Available
OMB No. 0917-0036, 60 Day FRN, Published.pdf	Supplementary Document	Uploaded 2015-05-13	Available
Supporting Statement for OMB No. 0917-0036, IHS Fast Track for Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery Part A - IHS FINAL 5-12-15v1.docx	Supporting Statement A	Uploaded 2015-05-13	Repair queued
Justification for Burden Increase.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2013-01-18	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
231605	Chinle Service Unit (CSU) Health Promotion/Disease Prevention	Form and Instruction	New	CSU Health Promotion survey
230847	Evaluation Survey of IHS Mandatory Pain and Opioid Training and Prescriber Habits	Form and Instruction	New	Evaluation Survey
230260	IHS White Earth Hand Washing Survey	Form and Instruction	New	Hand Washing Survey
229103	Fort Washakie Medical Home Patient Feedback	Form and Instruction	New	Fort Washakie Medical Home Patient Feedback
228427	Patient Satisfaction Survey, Optometry Dept. White Earth Service Unit Indian Health Service	Form and Instruction	New	Patient Satisfaction Survey for the White Earth Optometry Dept.
227895	Innovative Session Partnership Conference	Other-Discussion Questions	New
227765	IHS Training Needs Survey	Form and Instruction	New	Training Needs Survey
226315	IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition	Form	New	RDN Services Survey
226315	IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition	Form	New	Community Nutrition Gardening Survey
226049	WebTMA Survey	Form and Instruction	New	WebTMA Survey
225049	Telebehavioral Health Patient Satisfaction Survey	Form	New	Telebehavioral Health Patient Satisfaction Survey
225048	Public Health Nursing Data Mart Survey	Form and Instruction	New	Public Health Nursing (PHN) Data Mart Survey Questions
224877	Patient Experience of Care Survey Pilot Project	Form and Instruction	New	Patient Experience of Care Survey
223611	IHS Web Services Customer Satisfaction Survey	Form	New	IHS Web Services Customer Feedback
221047	PT/OT (Therapy Department) - Provision of Care Survey	Form and Instruction	New	PT/OT (Therapy Department) - Provision of Care Survey
218957	OMB Form No. 0917-0036, Indian Health Service (IHS) Community Health Representative (CHR) Basic Online Training Evaluation	Form and Instruction	New	IHS CHR Basic Online Training Evaluation
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	New	Public Health Nursing - for Patient
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	New	Public Health Nursing - for Patient Care Giver - Survey
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	New	Native Medicine Survey
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	New	Health Promotion Survey
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	New	Diabetes Survey
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	New	Community Nutrition Survey
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	New	Adolescent School Health
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	New	Wellness Center Survey
217933	Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit (CSU)	Form and Instruction	New	Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit CSU)
217932	Obstetric Care Unit (OCU) Patient Experience Survey, Chinle Service Unit	Form and Instruction	New	Obstetrical Care Unit (OCU) Patient Experience Suvey, Chinle Service Unit (CSU)
217748	Special Care Unit (SCU) Patient Experience Survey, Chinle Service Unit	Form and Instruction	New	Special Care Unit (SCU) Patient Experience Survey
217747	Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit (CSU)	Form and Instruction	New	Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit
217690	Chinle Service Unit (CSU) Employee Satisfaction Survey.	Form and Instruction	New	CSU Employee Survey 2015
217673	We Care Survey, Fort Peck Service Unit Indian Health Service	Form and Instruction	New	We Care Survey, Fort Peck Service Unit, Indian Health Service
216572	Clinical Decision Support Usability Assessment	Form and Instruction	New	Clinical Decision Support Usability Assessment
216564	Patient Satisfaction Survey, Crow Service Unit	Form and Instruction	New	Patient Satisfaction Survey, Crow Service Unit
216563	Sugar Shockers Health Campaign Survey, Catawba Service Unit	Form and Instruction	New	Sugar Shockers Health Campaign Survey, Catawba Service Unit
216545	User satisfaction data collection for the IHS OIT NDW	Form and Instruction	New	Indian Health Service, Office of Information Technology, National Patient Reporting System National Data Warehouse Data Collection Survey
216544	We Care Survey, Northern Cheyenne	Form and Instruction	New	We Care Patient Satisfaction Survey for Northern Cheyenne
216538	We Care Survey, Blackfeet Community Hospital.	Form and Instruction	New	We Care Survey, Blackfeet Community Hospital.
216534	Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey	Form and Instruction	New	Patient Wellness Survey
216534	Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey	Form and Instruction	New	Patient Registration Suvey
216534	Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey	Form and Instruction	New	Coordinated Care Survey
216532	Catawba Service Unit Patient Satisfaction Survey	Form and Instruction	New	Catawba Service Unit Patient Satisfaction Survey
216531	IHS RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment	Form and Instruction	New	Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment
216529	We Care Survey, Fort Peck Service Unit Indian Health Service	Form and Instruction	New	We Care Survey, Fort Peck Service Unit Indian Health Service
216517	THC Dental Patient Satisfaction Survey	Form and Instruction	New	THC Dental Patient Satisfaction Survey
216516	Patient Satisfaction Survey, Tohatchi	Form and Instruction	New	Patient Satisfaction Survey, Tohatchi
216515	Gallup Service Unit Patient Satisfaction Survey	Form and Instruction	New	Gallup Service Unit Patient Satisfaction Survey
216514	Patient Satisfaction Survey, Alburquerque Service Unit	Form and Instruction	New	Patient Satisfaction Survey, Alburquerque Service Unit
216513	Providers –e-RX Deployment Survey	Form and Instruction	New	Providers - e-RX Deployment Survey
216512	White Earth Dental Clinic Patient Satisfaction Survey	Form and Instruction	New	White Earth Dental Clinic Patient Satisfaction Survey
216510	Patient Flow Time Study	Form and Instruction	New	Patient Flow Time Study
216509	Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)	Form and Instruction	New	Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)
216501	EHR Pharmacy Residence Informaticists Survey	Form and Instruction	New	EHR Pharmacy Residence Informaticists Survey
216500	eLearning Hands-on Customer Satisfaction Survey	Form and Instruction	New	eLearning Hands-on Customer Satisfaction survey
216499	Computer Based Post Class Survey	Form and Instruction	New	Computer Based Training (CBT)Post Class Survey
216498	IHS Website ICD-10 Stakeholder Readiness Survey – ICD-10 Project Needs Assessment	Form and Instruction	New	IHS Website ICD-10 Stakeholder Readiness Survey – ICD-10 Project Needs Assessment
216493	IHS Patient Experience Survey	Form and Instruction	New	IHS Patient Experience Survey
216478	IHS RPMS Annual Training Needs Assessment Survey	Form and Instruction	New	IHS RPMS Annual Training Needs Assessment Survey
216474	VPN User Survey	Form and Instruction	New	VPN User Survey
216470	Portland Area Division of Environment Health Services: Customer Service Assessment.	Form and Instruction	New	Portland Area Division of Environment Health Services: Customer Service Assessment.
216465	IHS OEHE Customer Satisfaction Forms	Form and Instruction	New	Tribal Partner Survey
216465	IHS OEHE Customer Satisfaction Forms	Form and Instruction	New	Tribal Homeowner Survey
216465	IHS OEHE Customer Satisfaction Forms	Form and Instruction	New	Post-Construction O & M Survey
216465	IHS OEHE Customer Satisfaction Forms	Form and Instruction	New	Annual Operator O & M Survey
216464	IHS Pharmacy Automation 2015 Survey	Form and Instruction	New	IHS Pharmacy Automation 2015 Survey
216462	Indian Health Service (IHS) Clinical Rounds Qualitative Feedback	Form and Instruction	New	Indian Health Service (IHS) Clinical Rounds Qualitative Feedback
216457	IHS CHR NET Plenary Evaluation Form	Form and Instruction	New	IHS CHR NET Plenary Evaluation Form
216453	Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation	Form and Instruction	New	Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation
216452	IHS Community Health Representative Basic Training & Refresher Course Training form	Form and Instruction	New	IHS Community Health Representative Basic Training & Refresher Course Training form
216429	OIT Customer Satisfaction Survey – Problem Ticket	Form and Instruction	New	OIT Customer Satisfaction Survey – Problem Ticket (screen shot)
216429	OIT Customer Satisfaction Survey – Problem Ticket	Form and Instruction	New	OIT Customer Satisfaction Survey – Problem Ticket
216427	OIT Customer Satisfaction Survey-Service Ticket	Form and Instruction	New	OIT Customer Satisfaction Survey-Service Ticket (screen shot)
216427	OIT Customer Satisfaction Survey-Service Ticket	Form and Instruction	New	OIT Customer Satisfaction Survey-Service Ticket
216426	Physician/Dentist Customer Service Questionnaire	Form and Instruction	New	Physician/Dentist Customer Service Questionnaire
216424	Patient Assessment –Clinton Service Unit - IMPRESS	Form and Instruction	New	Patient Assessment –Clinton Service Unit - IMPRESS
216421	Employee Assessment- Clinton Service Unit - IMPRESS	Form and Instruction	New	Employee Assessment- Clinton Service Unit - IMPRESS
216417	Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey	Form and Instruction	New	FY___Satellite Classroom with Areas Post Class Survey
216417	Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey	Form and Instruction	New	Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey
216415	Indian Health Service (IHS) FY_ eLearning Post Class Survey	Form and Instruction	New	Indian Health Service (IHS) FY_ eLearning Post Class Survey
216412	Indian Health Service (IHS) FY_ Classroom Post Class Survey	Form and Instruction	New	Indian Health Service (IHS) FY_ Classroom Post Class Survey
216402	IHS Website Customer Satisfaction Survey – EHR Survey Monkey – VIRTUAL	Form and Instruction	New	IHS Website Customer Satisfaction Survey – EHR Survey Monkey – VIRTUAL
216397	IHS Website Customer Satisfaction Survey – EHR Survey Monkey – Classroom Form	Form and Instruction	New	IHS Website Customer Satisfaction Survey – EHR Survey Monkey – Classroom Form
216396	Indian Health Service (IHS Website Feedback Form	Form and Instruction	New	IHS Website Customer Satisfaction Survey - First Page
216396	Indian Health Service (IHS Website Feedback Form	Form and Instruction	New	IHS Website Feedback Form

ICR Details

OMB Control No: 0917-0036	ICR Reference No: 201504-0917-007
Status: Historical Active	Previous ICR Reference No: 201301-0917-001
Agency/Subagency: HHS/IHS	Agency Tracking No: 1
Title: Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: IHS Customer Service Satisfaction and Similar Surveys
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/28/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/13/2015
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.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2018	36 Months From Approved	07/31/2015
Responses	105,000	0	105,000
Time Burden (Hours)	17,500	0	40,000
Cost Burden (Dollars)	0	0	0

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Abstract: This fast track generic collection of information 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, efficient, and satisfying experience with the Agency's programs.

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Authorizing Statute(s): US Code: 44 USC 3501 Name of Law: Paperwork Reduction Act
   EO: EO 12862 Name/Subject of EO: SETTING CUSTOMER SERVICE STANDARDS
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 11206	03/02/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 27176	05/12/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 65

table that charts list of burden

IC Title	Form No.	Form Name
Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit (CSU)	0917-0036	Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit
Catawba Service Unit Patient Satisfaction Survey	0917-0036	Catawba Service Unit Patient Satisfaction Survey
Chinle Service Unit (CSU) Employee Satisfaction Survey.	0917-0036	CSU Employee Survey 2015
Chinle Service Unit (CSU) Health Promotion/Disease Prevention	0917-0036-58-3	CSU Health Promotion survey
Clinical Decision Support Usability Assessment	0917-0036	Clinical Decision Support Usability Assessment
Computer Based Post Class Survey	0917-0036	Computer Based Training (CBT)Post Class Survey
EHR Pharmacy Residence Informaticists Survey	0917-0036	EHR Pharmacy Residence Informaticists Survey
Employee Assessment- Clinton Service Unit - IMPRESS	0917-0036	Employee Assessment- Clinton Service Unit - IMPRESS
Evaluation Survey of IHS Mandatory Pain and Opioid Training and Prescriber Habits	0917-0036	Evaluation Survey
Fort Washakie Medical Home Patient Feedback	0917-0036	Fort Washakie Medical Home Patient Feedback
Gallup Service Unit Patient Satisfaction Survey	0917-0036	Gallup Service Unit Patient Satisfaction Survey
IHS CHR NET Plenary Evaluation Form	0917-0036	IHS CHR NET Plenary Evaluation Form
IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition	0917-0036, 0917-0036	Community Nutrition Gardening Survey ,   RDN Services Survey
IHS Community Health Representative Basic Training & Refresher Course Training form	0917-0036	IHS Community Health Representative Basic Training & Refresher Course Training form
IHS OEHE Customer Satisfaction Forms	0917-0036, 0917-0036, 0917-0036, 0917-0036	Annual Operator O & M Survey ,   Post-Construction O & M Survey ,   Tribal Homeowner Survey ,   Tribal Partner Survey
IHS Patient Experience Survey	0917-0036	IHS Patient Experience Survey
IHS Pharmacy Automation 2015 Survey	0917-0036	IHS Pharmacy Automation 2015 Survey
IHS RPMS Annual Training Needs Assessment Survey	0917-0036	IHS RPMS Annual Training Needs Assessment Survey
IHS RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment	0917-0036	Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment
IHS Training Needs Survey	0917-0036-23	Training Needs Survey
IHS Web Services Customer Satisfaction Survey	IHS Web Services Customer Feedback	IHS Web Services Customer Feedback
IHS Website Customer Satisfaction Survey – EHR Survey Monkey – Classroom Form	0917-0036	IHS Website Customer Satisfaction Survey – EHR Survey Monkey – Classroom Form
IHS Website Customer Satisfaction Survey – EHR Survey Monkey – VIRTUAL	0917-0036	IHS Website Customer Satisfaction Survey – EHR Survey Monkey – VIRTUAL
IHS Website ICD-10 Stakeholder Readiness Survey – ICD-10 Project Needs Assessment	0917-0036	IHS Website ICD-10 Stakeholder Readiness Survey – ICD-10 Project Needs Assessment
IHS White Earth Hand Washing Survey	0917-0036	Hand Washing Survey
Indian Health Service (IHS Website Feedback Form	0917-0036, 0917-0036	IHS Website Feedback Form ,   IHS Website Customer Satisfaction Survey - First Page
Indian Health Service (IHS) Clinical Rounds Qualitative Feedback	0917-0036	Indian Health Service (IHS) Clinical Rounds Qualitative Feedback
Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation	0917-0036	Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation
Indian Health Service (IHS) FY_ Classroom Post Class Survey	0917-0036	Indian Health Service (IHS) FY_ Classroom Post Class Survey
Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey	0917-0036, 0917-0036	Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey ,   FY___Satellite Classroom with Areas Post Class Survey
Indian Health Service (IHS) FY_ eLearning Post Class Survey	0917-0036	Indian Health Service (IHS) FY_ eLearning Post Class Survey
Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey	0917-0036, 0917-0036, 0917-0036	Coordinated Care Survey ,   Patient Registration Suvey ,   Patient Wellness Survey
Innovative Session Partnership Conference
OIT Customer Satisfaction Survey – Problem Ticket	0917-0036, 0917-0036	OIT Customer Satisfaction Survey – Problem Ticket ,   OIT Customer Satisfaction Survey – Problem Ticket (screen shot)
OIT Customer Satisfaction Survey-Service Ticket	0917-0036, 0917-0036	OIT Customer Satisfaction Survey-Service Ticket ,   OIT Customer Satisfaction Survey-Service Ticket (screen shot)
OMB Form No. 0917-0036, Indian Health Service (IHS) Community Health Representative (CHR) Basic Online Training Evaluation	0917-0036	IHS CHR Basic Online Training Evaluation
OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036	Wellness Center Survey ,   Adolescent School Health ,   Community Nutrition Survey ,   Diabetes Survey ,   Health Promotion Survey ,   Native Medicine Survey ,   Public Health Nursing - for Patient Care Giver - Survey ,   Public Health Nursing - for Patient
Obstetric Care Unit (OCU) Patient Experience Survey, Chinle Service Unit	0917-0036	Obstetrical Care Unit (OCU) Patient Experience Suvey, Chinle Service Unit (CSU)
PT/OT (Therapy Department) - Provision of Care Survey	0917-0036	PT/OT (Therapy Department) - Provision of Care Survey
Patient Assessment –Clinton Service Unit - IMPRESS	0917-0036	Patient Assessment –Clinton Service Unit - IMPRESS
Patient Experience of Care Survey Pilot Project	0917-0036	Patient Experience of Care Survey
Patient Flow Time Study	0917-0036	Patient Flow Time Study
Patient Satisfaction Survey, Alburquerque Service Unit	0917-0036	Patient Satisfaction Survey, Alburquerque Service Unit
Patient Satisfaction Survey, Crow Service Unit	0917-0036	Patient Satisfaction Survey, Crow Service Unit
Patient Satisfaction Survey, Optometry Dept. White Earth Service Unit Indian Health Service	0917-0036-12	Patient Satisfaction Survey for the White Earth Optometry Dept.
Patient Satisfaction Survey, Tohatchi	0917-0036	Patient Satisfaction Survey, Tohatchi
Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)	0917-0036	Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)
Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit (CSU)	0917-0036	Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit CSU)
Physician/Dentist Customer Service Questionnaire	0917-0036	Physician/Dentist Customer Service Questionnaire
Portland Area Division of Environment Health Services: Customer Service Assessment.	0917-0036	Portland Area Division of Environment Health Services: Customer Service Assessment.
Providers –e-RX Deployment Survey	0917-0036	Providers - e-RX Deployment Survey
Public Health Nursing Data Mart Survey	0917-0036	Public Health Nursing (PHN) Data Mart Survey Questions
Special Care Unit (SCU) Patient Experience Survey, Chinle Service Unit	0917-0036	Special Care Unit (SCU) Patient Experience Survey
Sugar Shockers Health Campaign Survey, Catawba Service Unit	0917-0036	Sugar Shockers Health Campaign Survey, Catawba Service Unit
THC Dental Patient Satisfaction Survey	0917-0036	THC Dental Patient Satisfaction Survey
Telebehavioral Health Patient Satisfaction Survey	0917-0036	Telebehavioral Health Patient Satisfaction Survey
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
VPN User Survey	0917-0036	VPN User Survey
We Care Survey, Blackfeet Community Hospital.	0917-0036	We Care Survey, Blackfeet Community Hospital.
We Care Survey, Fort Peck Service Unit Indian Health Service	0917-0036	We Care Survey, Fort Peck Service Unit, Indian Health Service
We Care Survey, Fort Peck Service Unit Indian Health Service	0917-0036	We Care Survey, Fort Peck Service Unit Indian Health Service
We Care Survey, Northern Cheyenne	0917-0036	We Care Patient Satisfaction Survey for Northern Cheyenne
WebTMA Survey	0917-0036	WebTMA Survey
White Earth Dental Clinic Patient Satisfaction Survey	0917-0036	White Earth Dental Clinic Patient Satisfaction Survey
eLearning Hands-on Customer Satisfaction Survey	0917-0036	eLearning Hands-on Customer Satisfaction survey

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ICR Summary of Burden

table that charts list 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	105,000	0	0	0	0
Annual Time Burden (Hours)	17,500	40,000	0	0	-22,500	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: This is a request for an extension of a previously approved generic ICR. There were no program changes. However, there was a change in burden hours due to adjustments in the Agency's estimate. The number of total burden hours was reduced (from 40,000 burden hours to 17,500) to more accurately reflect the actual burden hours. The increase in costs (from $15,000 to $25,000) to the Federal government was also modified to more accurately reflect the actual and projected costs for the next three years.

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Annual Cost to Federal Government: $25,000

Does this IC contain surveys, censuses, or employ statistical methods? No

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

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Common Form ICR:  No

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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: 05/13/2015

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