Information Collection

Physician/Dentist Customer Service Questionnaire

IC 216426 under ICR 201504-0917-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Physician/Dentist Customer Service Questionnaire	Form and Instruction
0917-0036 Physician/Dentist Customer Service Questionnaire OMB No. 0917-0036-12, Physician & Dentist Customer Service Questionnaire - 2015.docx	Form and Instruction
OMB No. 0917-0036-12 Mini Supporting Statement - 2015.doc OMB No. 0917-0036, Mini-Supporting Statement for Physician/Dentist Customer Service Questionnaire	IC Document

IC Title:

Physician/Dentist Customer Service Questionnaire

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	0917-0036	Physician/Dentist Customer Service Questionnaire	OMB No. 0917-0036-12, Physician & Dentist Customer Service Questionnaire - 2015.docx		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	42	42
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 for Physician/Dentist Customer Service Questionnaire	OMB No. 0917-0036-12 Mini Supporting Statement - 2015.doc	05/05/2015

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