Information Collection

Patient Experience of Care Survey Pilot Project

IC 224877 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⚠️ Notice: This information collection may be referencing outdated material.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 Patient Experience of Care Survey Pilot Project	Form and Instruction
0917-0036 Patient Experience of Care Survey SURVEY PREVIEW MODE IHS Pilot Survey Final.docx	Form and Instruction
12.7.2016_Brochure_IHSPatient Experience of Care Survey.docx Patient Experience of Care Brochure	IC Document
IHS_Patient Exp Script12.9.2016.docx Patient Experience of Care Script	IC Document
12 12 2016 OMB IHS Patient Exp of Care.doc Request for Approval - Patient Experience of Care Survey Pilot Project	IC Document

IC Title:

Patient Experience of Care Survey Pilot Project

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	Patient Experience of Care Survey	SURVEY PREVIEW MODE IHS Pilot Survey Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,000

Number of Respondents for Small Entity: 1,000

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	467	467
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Patient Experience of Care Brochure	12.7.2016_Brochure_IHSPatient Experience of Care Survey.docx	12/22/2016
Patient Experience of Care Script	IHS_Patient Exp Script12.9.2016.docx	12/22/2016
Request for Approval - Patient Experience of Care Survey Pilot Project	12 12 2016 OMB IHS Patient Exp of Care.doc	12/22/2016

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