Information Collection

IHS Patient Experience Survey

IC 216493 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⚠️ Notice: This information collection may be referencing outdated material.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 IHS Patient Experience Survey	Form and Instruction
0917-0036 IHS 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 OMB No. 0917-0036, Mini-supporting Staement for IHS Patient Experience Survey	IC Document

IC Title:

IHS Patient Experience Survey

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	IHS Patient Experience Survey	OMB 0917-0036-24, IPC Patient Experience Survey Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	3	3
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 Staement for IHS Patient Experience Survey	OMB 0917-0036-24, Mini-Supporting Statement for IPC Patient Experience Survey.doc	05/07/2015

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