Information Collection

THC Dental Patient Satisfaction Survey

IC 216517 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⚠️ Notice: This information collection may be referencing outdated material.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 THC Dental Patient Satisfaction Survey	Form and Instruction
0917-0036 THC Dental Patient Satisfaction Survey OMB No. 0917-0036-40, THC Dental Patient Satisfaction Survey.docx	Form and Instruction
OMB No. 0917-0036-40, Mini-supporting Statement for THC Dental Patient Satisfaction Survey.doc OMB No. 0917-0036, Mini-Supporting Statement for THC Dental Patient Satisfaction Survey	IC Document

IC Title:

THC Dental Patient Satisfaction 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	THC Dental Patient Satisfaction Survey	OMB No. 0917-0036-40, THC Dental Patient Satisfaction Survey.docx		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 360

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	360	360
Annual IC Time Burden (Hours)	30	30
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 THC Dental Patient Satisfaction Survey	OMB No. 0917-0036-40, Mini-supporting Statement for THC Dental Patient Satisfaction Survey.doc	05/08/2015

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