Information Collection

OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.

IC 218239 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⚠️ Notice: This information collection may be referencing outdated material.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 OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction
0917-0036 Wellness Center Survey 0917-0036-Chinle Wellness Center Client Survey.docx	Form and Instruction
0917-0036 Adolescent School Health 0917-0036-Adolescent and School Health Survey.docx	Form and Instruction
0917-0036 Community Nutrition Survey 0917-0036-Community Nutrition Food Demo Survey.docx	Form and Instruction
0917-0036 Diabetes Survey 0917-0036-Diabetes Services Survey.docx	Form and Instruction
0917-0036 Health Promotion Survey 0917-0036-Health Promotion Survey.docx	Form and Instruction
0917-0036 Native Medicine Survey 0917-0036-Native Medicine Survey.docx	Form and Instruction
0917-0036 Public Health Nursing - for Patient Care Giver - Survey 0917-0036-PHN Customer Services Survey Care Giver.docx	Form and Instruction
0917-0036 Public Health Nursing - for Patient 0917-0036-PHN Customer Services Survey.docx	Form and Instruction
2015 Generic Clearance Submission - Public Health Customer Satisfaction Survey with tjohnson changes 9 15 15.docx OMB No. 0917-0036, Supporting Statement for IHS Chinle Service Unit Customer Experience Survey, Division of Public Health	IC Document

IC Title:

OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0917-0036	Wellness Center Survey	0917-0036-Chinle Wellness Center Client Survey.docx	Yes	No	Printable Only
Form and Instruction	0917-0036	Adolescent School Health	0917-0036-Adolescent and School Health Survey.docx	Yes	No	Printable Only
Form and Instruction	0917-0036	Community Nutrition Survey	0917-0036-Community Nutrition Food Demo Survey.docx	Yes	No	Printable Only
Form and Instruction	0917-0036	Diabetes Survey	0917-0036-Diabetes Services Survey.docx	Yes	No	Printable Only
Form and Instruction	0917-0036	Health Promotion Survey	0917-0036-Health Promotion Survey.docx	Yes	No	Printable Only
Form and Instruction	0917-0036	Native Medicine Survey	0917-0036-Native Medicine Survey.docx	Yes	No	Printable Only
Form and Instruction	0917-0036	Public Health Nursing - for Patient Care Giver - Survey	0917-0036-PHN Customer Services Survey Care Giver.docx	Yes	No	Printable Only
Form and Instruction	0917-0036	Public Health Nursing - for Patient	0917-0036-PHN Customer Services Survey.docx	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16,200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	16,200	16,200
Annual IC Time Burden (Hours)	810	810
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
OMB No. 0917-0036, Supporting Statement for IHS Chinle Service Unit Customer Experience Survey, Division of Public Health	2015 Generic Clearance Submission - Public Health Customer Satisfaction Survey with tjohnson changes 9 15 15.docx	09/17/2015

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