Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: IHS Customer Service Satisfaction and Similar Surveys

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0917-0036 HCW Application	Form and Instruction	New	Repair queued
Form 0917-0036 Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey	Form and Instruction	New	Repair queued
Form 9017-0036 Patient Survey	Form and Instruction	New	Repair queued
Form 0917-0036 Classroom Survey	Form and Instruction	New	Repair queued
Form 0916-0036 ELearning Survey	Form and Instruction	New	Repair queued
Form 0917-0036 Lab Survey	Form and Instruction	New	Repair queued
Form 0917-0036 Anticoagulation Clinic Patient Satisfaction Survey	Form and Instruction	New	Repair queued
Form 9017 9017	Form and Instruction	New	Repair queued
Form 8 Radiology Patient Satisfaction Survey	Form and Instruction	New	Repair queued
Form 7 Physcial Therapy Patient Satisfaction Survey	Form and Instruction	New	Repair queued
Form 6 Pharmacy Patient Satisfaction Survey	Form and Instruction	New	Repair queued
Form 5 Optometry Patient Satisfaction Survey	Form and Instruction	New	Repair queued
Form 4 Nutrition Services Patient Satisfaction Survey	Form and Instruction	New	Repair queued
Form 3 Laboratory Patient Satisfaction Survey	Form and Instruction	New	Repair queued
Form 2 Dental Patient Satisfaction Survey	Form and Instruction	New	Repair queued
Form 1 Behavioral Health Patient Satisfaction Survey	Form and Instruction	New	Repair queued
Form 0917-0036 FY21 OIT RPMS Training Needs Assessment Survey	Form and Instruction	New	Available
Form 0917-0036 Therapist Survey	Form and Instruction	New	Available
Form 0917-0036 Radiology Dept Survey	Form and Instruction	New	Available
Form 0917-0036 Optometry Survey	Form and Instruction	New	Available
Form 0917-0036 Lab Dept Survey	Form and Instruction	New	Available
Form 0917-0036 Dental Survey	Form and Instruction	New	Available
Form 0917-0036 Diabetes Care Survey	Form and Instruction	New	Available
Form 0917-0036 Gardening Survey	Form and Instruction	New	Available
Form 0917-0036 Community Nutrition	Form and Instruction	New	Available
Form 9017-0036 HPV Survey	Form and Instruction	New	Available
Form 9017-0036 LHP Behaviorial Health Training Needs Survey	Form and Instruction	New	Available
Form 87-1 PrEP Questionnaire	Form and Instruction	New	Available
Form 87 MAT Provider Survey	Form and Instruction	New	Available
Form 0917-0036-86 Confer Satisfaction Survey	Form	New	Available
Form 9017-0036 IHS CHR Survey	Form and Instruction	New	Available
Form 0917-0036 Evaluation Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Hand Washing Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Fort Washakie Medical Home Patient Feedback	Form and Instruction	Unchanged	Available
Form 0917-0036-12 Patient Satisfaction Survey for the White Earth Optometry Dept.	Form and Instruction	Unchanged	Available
Form 0917-0036-23 Training Needs Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 RDN Services Survey	Form	Unchanged	Available
Form 0917-0036 Community Nutrition Gardening Survey	Form	Unchanged	Available
Form 0917-0036 WebTMA Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Telebehavioral Health Patient Satisfaction Survey	Form	Unchanged	Available
Form 0917-0036 Public Health Nursing (PHN) Data Mart Survey Questions	Form and Instruction	Unchanged	Available
Form 0917-0036 Patient Experience of Care Survey	Form and Instruction	Unchanged	Available
Form IHS Web Services C IHS Web Services Customer Feedback	Form	Unchanged	Available
Form 0917-0036 PT/OT (Therapy Department) - Provision of Care Survey	Form and Instruction	Removed	Repair queued
Form 0917-0036 IHS CHR Basic Online Training Evaluation	Form and Instruction	Removed	Available
Form 0917-0036 Public Health Nursing - for Patient	Form and Instruction	Unchanged	Available
Form 0917-0036 Public Health Nursing - for Patient Care Giver - Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Native Medicine Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Health Promotion Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Diabetes Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Community Nutrition Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Adolescent School Health	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Wellness Center Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit CSU)	Form and Instruction	Unchanged	Available
Form 0917-0036 Obstetrical Care Unit (OCU) Patient Experience Suvey, Chinle Service Unit (CSU)	Form and Instruction	Unchanged	Available
Form 0917-0036 Special Care Unit (SCU) Patient Experience Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit	Form and Instruction	Unchanged	Available
Form 0917-0036 CSU Employee Survey 2015	Form and Instruction	Unchanged	Available
Form 0917-0036 We Care Survey, Fort Peck Service Unit, Indian Health Service	Form and Instruction	Unchanged	Available
Form 0917-0036 Clinical Decision Support Usability Assessment	Form and Instruction	Unchanged	Available
Form 0917-0036 Patient Satisfaction Survey, Crow Service Unit	Form and Instruction	Removed	Available
Form 0917-0036 Sugar Shockers Health Campaign Survey, Catawba Service Unit	Form and Instruction	Removed	Available
Form 0917-0036 Indian Health Service, Office of Information Technology, National Patient Reporting System National Data Warehouse Data Collection Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 We Care Patient Satisfaction Survey for Northern Cheyenne	Form and Instruction	Unchanged	Available
Form 0917-0036 We Care Survey, Blackfeet Community Hospital.	Form and Instruction	Unchanged	Available
Form 0917-0036 Patient Wellness Survey	Form and Instruction	Removed	Available
Form 0917-0036 Patient Registration Suvey	Form and Instruction	Removed	Available
Form 0917-0036 Coordinated Care Survey	Form and Instruction	Removed	Available
Form 0917-0036 Catawba Service Unit Patient Satisfaction Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment	Form and Instruction	Unchanged	Available
Form 0917-0036 We Care Survey, Fort Peck Service Unit Indian Health Service	Form and Instruction	Unchanged	Available
Form 0917-0036 THC Dental Patient Satisfaction Survey	Form and Instruction	Removed	Available
Form 0917-0036 Patient Satisfaction Survey, Tohatchi	Form and Instruction	Removed	Available
Form 0917-0036 Gallup Service Unit Patient Satisfaction Survey	Form and Instruction	Removed	Available
Form 0917-0036 Patient Satisfaction Survey, Alburquerque Service Unit	Form and Instruction	Unchanged	Available
Form 0917-0036 Providers - e-RX Deployment Survey	Form and Instruction	Removed	Available
Form 0917-0036 White Earth Dental Clinic Patient Satisfaction Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Patient Flow Time Study	Form and Instruction	Unchanged	Available
Form 0917-0036 Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)	Form and Instruction	Unchanged	Available
Form 0917-0036 EHR Pharmacy Residence Informaticists Survey	Form and Instruction	Removed	Available
Form 0917-0036 eLearning Hands-on Customer Satisfaction survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Computer Based Training (CBT)Post Class Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 IHS Website ICD-10 Stakeholder Readiness Survey – ICD-10 Project Needs Assessment	Form and Instruction	Removed	Available
Form 0917-0036 IHS Patient Experience Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 IHS RPMS Annual Training Needs Assessment Survey	Form and Instruction	Removed	Available
Form 0917-0036 VPN User Survey	Form and Instruction	Removed	Available
Form 0917-0036 Portland Area Division of Environment Health Services: Customer Service Assessment.	Form and Instruction	Removed	Repair queued
Form 0917-0036 Tribal Partner Survey	Form and Instruction	Removed	Available
Form 0917-0036 Tribal Homeowner Survey	Form and Instruction	Removed	Available
Form 0917-0036 Post-Construction O & M Survey	Form and Instruction	Removed	Available
Form 0917-0036 Annual Operator O & M Survey	Form and Instruction	Removed	Available
Form 0917-0036 IHS Pharmacy Automation 2015 Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Indian Health Service (IHS) Clinical Rounds Qualitative Feedback	Form and Instruction	Unchanged	Available
Form 0917-0036 IHS CHR NET Plenary Evaluation Form	Form and Instruction	Unchanged	Available
Form 0917-0036 Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation	Form and Instruction	Unchanged	Available
Form 0917-0036 IHS Community Health Representative Basic Training & Refresher Course Training form	Form and Instruction	Removed	Available
Form 0917-0036 OIT Customer Satisfaction Survey – Problem Ticket (screen shot)	Form and Instruction	Unchanged	Available
Form 0917-0036 OIT Customer Satisfaction Survey – Problem Ticket	Form and Instruction	Unchanged	Available
Form 0917-0036 OIT Customer Satisfaction Survey-Service Ticket (screen shot)	Form and Instruction	Removed	Available
Form 0917-0036 OIT Customer Satisfaction Survey-Service Ticket	Form and Instruction	Removed	Available
Form 0917-0036 Physician/Dentist Customer Service Questionnaire	Form and Instruction	Unchanged	Available
Form 0917-0036 Patient Assessment –Clinton Service Unit - IMPRESS	Form and Instruction	Unchanged	Available
Form 0917-0036 Employee Assessment- Clinton Service Unit - IMPRESS	Form and Instruction	Unchanged	Available
Form 0917-0036 FY___Satellite Classroom with Areas Post Class Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Indian Health Service (IHS) FY_ eLearning Post Class Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Indian Health Service (IHS) FY_ Classroom Post Class Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 IHS Website Customer Satisfaction Survey – EHR Survey Monkey – VIRTUAL	Form and Instruction	Removed	Available
Form 0917-0036 IHS Website Customer Satisfaction Survey – EHR Survey Monkey – Classroom Form	Form and Instruction	Removed	Available
Form 0917-0036 IHS Website Customer Satisfaction Survey - First Page	Form and Instruction	Unchanged	Available
Form 0917-0036 IHS Website Feedback Form	Form and Instruction	Unchanged	Available
Supporting Statement A for OMB No. 0917-0036, IHS Fast Track for Generic Clearance 2018.docx	Supporting Statement A	Uploaded 2018-07-11	Available
Justification for Burden Increase.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2013-01-18	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
250384	Indian Health Service National Health Coaching Pilot Project Registration	Form and Instruction	New	HCW Application
250081	Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey	Form and Instruction	New	Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey
250077	Patient Satisfaction Survey - Crownpoint Service Unit	Form and Instruction	New	Patient Survey
249370	OIT RPMS Training Post Class Survey	Form and Instruction	New	Classroom Survey
249370	OIT RPMS Training Post Class Survey	Form and Instruction	New	ELearning Survey
249152	Laboratory Training Evaluation	Form and Instruction	New	Lab Survey
248810	Anticoagulation Clinic Patient Satisfaction Survey	Form and Instruction	New	Anticoagulation Clinic Patient Satisfaction Survey
248668	Health Promotion Disease Prevention Activities Registration	Form and Instruction	New	9017
247004	WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	Form and Instruction	New	Radiology Patient Satisfaction Survey
247004	WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	Form and Instruction	New	Physcial Therapy Patient Satisfaction Survey
247004	WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	Form and Instruction	New	Pharmacy Patient Satisfaction Survey
247004	WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	Form and Instruction	New	Optometry Patient Satisfaction Survey
247004	WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	Form and Instruction	New	Nutrition Services Patient Satisfaction Survey
247004	WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	Form and Instruction	New	Laboratory Patient Satisfaction Survey
247004	WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	Form and Instruction	New	Dental Patient Satisfaction Survey
247004	WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	Form and Instruction	New	Behavioral Health Patient Satisfaction Survey
242056	OIT RPMS Training Needs Assessment Survey	Form and Instruction	New	FY21 OIT RPMS Training Needs Assessment Survey
237875	Patient Experience Surveys - White Earth Service Unit	Form and Instruction	New	Therapist Survey
237875	Patient Experience Surveys - White Earth Service Unit	Form and Instruction	New	Radiology Dept Survey
237875	Patient Experience Surveys - White Earth Service Unit	Form and Instruction	New	Optometry Survey
237875	Patient Experience Surveys - White Earth Service Unit	Form and Instruction	New	Lab Dept Survey
237875	Patient Experience Surveys - White Earth Service Unit	Form and Instruction	New	Dental Survey
237873	Diabetes Care Survey	Form and Instruction	New	Diabetes Care Survey
236418	IHS Chinle Service Unit Customer Experience Survey	Form and Instruction	New	Gardening Survey
236418	IHS Chinle Service Unit Customer Experience Survey	Form and Instruction	New	Community Nutrition
236413	Dental Professionals & Human Papillomavirus (HPV) Prevention Survey	Form and Instruction	New	HPV Survey
236408	Tele-Behavioral Health Center of Excellence (TBHCE) Survey	Form and Instruction	New	LHP Behaviorial Health Training Needs Survey
235443	Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey	Form and Instruction	New	PrEP Questionnaire
235443	Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey	Form and Instruction	New	MAT Provider Survey
235441	Confer Satisfaction Survey	Form	New	Confer Satisfaction Survey
235243	IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey	Form and Instruction	New	IHS CHR Survey
230847	Evaluation Survey of IHS Mandatory Pain and Opioid Training and Prescriber Habits	Form and Instruction	Unchanged	Evaluation Survey
230260	IHS White Earth Hand Washing Survey	Form and Instruction	Unchanged	Hand Washing Survey
229103	Fort Washakie Medical Home Patient Feedback	Form and Instruction	Unchanged	Fort Washakie Medical Home Patient Feedback
228427	Patient Satisfaction Survey, Optometry Dept. White Earth Service Unit Indian Health Service	Form and Instruction	Unchanged	Patient Satisfaction Survey for the White Earth Optometry Dept.
227895	Innovative Session Partnership Conference	Other-Discussion Questions	Unchanged
227765	IHS Training Needs Survey	Form and Instruction	Unchanged	Training Needs Survey
226315	IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition	Form	Unchanged	RDN Services Survey
226315	IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition	Form	Unchanged	Community Nutrition Gardening Survey
226049	WebTMA Survey	Form and Instruction	Unchanged	WebTMA Survey
225049	Telebehavioral Health Patient Satisfaction Survey	Form	Unchanged	Telebehavioral Health Patient Satisfaction Survey
225048	Public Health Nursing Data Mart Survey	Form and Instruction	Unchanged	Public Health Nursing (PHN) Data Mart Survey Questions
224877	Patient Experience of Care Survey Pilot Project	Form and Instruction	Unchanged	Patient Experience of Care Survey
223611	IHS Web Services Customer Satisfaction Survey	Form	Unchanged	IHS Web Services Customer Feedback
221047	PT/OT (Therapy Department) - Provision of Care Survey	Form and Instruction	Removed	PT/OT (Therapy Department) - Provision of Care Survey
218957	OMB Form No. 0917-0036, Indian Health Service (IHS) Community Health Representative (CHR) Basic Online Training Evaluation	Form and Instruction	Removed	IHS CHR Basic Online Training Evaluation
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	Unchanged	Public Health Nursing - for Patient
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	Unchanged	Public Health Nursing - for Patient Care Giver - Survey
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	Unchanged	Native Medicine Survey
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	Unchanged	Health Promotion Survey
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	Unchanged	Diabetes Survey
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	Unchanged	Community Nutrition Survey
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	Unchanged	Adolescent School Health
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	Unchanged	Wellness Center Survey
217933	Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit (CSU)	Form and Instruction	Unchanged	Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit CSU)
217932	Obstetric Care Unit (OCU) Patient Experience Survey, Chinle Service Unit	Form and Instruction	Unchanged	Obstetrical Care Unit (OCU) Patient Experience Suvey, Chinle Service Unit (CSU)
217748	Special Care Unit (SCU) Patient Experience Survey, Chinle Service Unit	Form and Instruction	Unchanged	Special Care Unit (SCU) Patient Experience Survey
217747	Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit (CSU)	Form and Instruction	Unchanged	Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit
217690	Chinle Service Unit (CSU) Employee Satisfaction Survey.	Form and Instruction	Unchanged	CSU Employee Survey 2015
217673	We Care Survey, Fort Peck Service Unit Indian Health Service	Form and Instruction	Unchanged	We Care Survey, Fort Peck Service Unit, Indian Health Service
216572	Clinical Decision Support Usability Assessment	Form and Instruction	Unchanged	Clinical Decision Support Usability Assessment
216564	Patient Satisfaction Survey, Crow Service Unit	Form and Instruction	Removed	Patient Satisfaction Survey, Crow Service Unit
216563	Sugar Shockers Health Campaign Survey, Catawba Service Unit	Form and Instruction	Removed	Sugar Shockers Health Campaign Survey, Catawba Service Unit
216545	User satisfaction data collection for the IHS OIT NDW	Form and Instruction	Unchanged	Indian Health Service, Office of Information Technology, National Patient Reporting System National Data Warehouse Data Collection Survey
216544	We Care Survey, Northern Cheyenne	Form and Instruction	Unchanged	We Care Patient Satisfaction Survey for Northern Cheyenne
216538	We Care Survey, Blackfeet Community Hospital.	Form and Instruction	Unchanged	We Care Survey, Blackfeet Community Hospital.
216534	Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey	Form and Instruction	Removed	Patient Wellness Survey
216534	Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey	Form and Instruction	Removed	Patient Registration Suvey
216534	Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey	Form and Instruction	Removed	Coordinated Care Survey
216532	Catawba Service Unit Patient Satisfaction Survey	Form and Instruction	Unchanged	Catawba Service Unit Patient Satisfaction Survey
216531	IHS RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment	Form and Instruction	Unchanged	Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment
216529	We Care Survey, Fort Peck Service Unit Indian Health Service	Form and Instruction	Unchanged	We Care Survey, Fort Peck Service Unit Indian Health Service
216517	THC Dental Patient Satisfaction Survey	Form and Instruction	Removed	THC Dental Patient Satisfaction Survey
216516	Patient Satisfaction Survey, Tohatchi	Form and Instruction	Removed	Patient Satisfaction Survey, Tohatchi
216515	Gallup Service Unit Patient Satisfaction Survey	Form and Instruction	Removed	Gallup Service Unit Patient Satisfaction Survey
216514	Patient Satisfaction Survey, Alburquerque Service Unit	Form and Instruction	Unchanged	Patient Satisfaction Survey, Alburquerque Service Unit
216513	Providers –e-RX Deployment Survey	Form and Instruction	Removed	Providers - e-RX Deployment Survey
216512	White Earth Dental Clinic Patient Satisfaction Survey	Form and Instruction	Unchanged	White Earth Dental Clinic Patient Satisfaction Survey
216510	Patient Flow Time Study	Form and Instruction	Unchanged	Patient Flow Time Study
216509	Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)	Form and Instruction	Unchanged	Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)
216501	EHR Pharmacy Residence Informaticists Survey	Form and Instruction	Removed	EHR Pharmacy Residence Informaticists Survey
216500	eLearning Hands-on Customer Satisfaction Survey	Form and Instruction	Unchanged	eLearning Hands-on Customer Satisfaction survey
216499	Computer Based Post Class Survey	Form and Instruction	Unchanged	Computer Based Training (CBT)Post Class Survey
216498	IHS Website ICD-10 Stakeholder Readiness Survey – ICD-10 Project Needs Assessment	Form and Instruction	Removed	IHS Website ICD-10 Stakeholder Readiness Survey – ICD-10 Project Needs Assessment
216493	IHS Patient Experience Survey	Form and Instruction	Unchanged	IHS Patient Experience Survey
216478	IHS RPMS Annual Training Needs Assessment Survey	Form and Instruction	Removed	IHS RPMS Annual Training Needs Assessment Survey
216474	VPN User Survey	Form and Instruction	Removed	VPN User Survey
216470	Portland Area Division of Environment Health Services: Customer Service Assessment.	Form and Instruction	Removed	Portland Area Division of Environment Health Services: Customer Service Assessment.
216465	IHS OEHE Customer Satisfaction Forms	Form and Instruction	Removed	Tribal Partner Survey
216465	IHS OEHE Customer Satisfaction Forms	Form and Instruction	Removed	Tribal Homeowner Survey
216465	IHS OEHE Customer Satisfaction Forms	Form and Instruction	Removed	Post-Construction O & M Survey
216465	IHS OEHE Customer Satisfaction Forms	Form and Instruction	Removed	Annual Operator O & M Survey
216464	IHS Pharmacy Automation 2015 Survey	Form and Instruction	Unchanged	IHS Pharmacy Automation 2015 Survey
216462	Indian Health Service (IHS) Clinical Rounds Qualitative Feedback	Form and Instruction	Unchanged	Indian Health Service (IHS) Clinical Rounds Qualitative Feedback
216457	IHS CHR NET Plenary Evaluation Form	Form and Instruction	Unchanged	IHS CHR NET Plenary Evaluation Form
216453	Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation	Form and Instruction	Unchanged	Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation
216452	IHS Community Health Representative Basic Training & Refresher Course Training form	Form and Instruction	Removed	IHS Community Health Representative Basic Training & Refresher Course Training form
216429	OIT Customer Satisfaction Survey – Problem Ticket	Form and Instruction	Unchanged	OIT Customer Satisfaction Survey – Problem Ticket (screen shot)
216429	OIT Customer Satisfaction Survey – Problem Ticket	Form and Instruction	Unchanged	OIT Customer Satisfaction Survey – Problem Ticket
216427	OIT Customer Satisfaction Survey-Service Ticket	Form and Instruction	Removed	OIT Customer Satisfaction Survey-Service Ticket (screen shot)
216427	OIT Customer Satisfaction Survey-Service Ticket	Form and Instruction	Removed	OIT Customer Satisfaction Survey-Service Ticket
216426	Physician/Dentist Customer Service Questionnaire	Form and Instruction	Unchanged	Physician/Dentist Customer Service Questionnaire
216424	Patient Assessment –Clinton Service Unit - IMPRESS	Form and Instruction	Unchanged	Patient Assessment –Clinton Service Unit - IMPRESS
216421	Employee Assessment- Clinton Service Unit - IMPRESS	Form and Instruction	Unchanged	Employee Assessment- Clinton Service Unit - IMPRESS
216417	Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey	Form and Instruction	Unchanged	FY___Satellite Classroom with Areas Post Class Survey
216417	Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey	Form and Instruction	Unchanged	Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey
216415	Indian Health Service (IHS) FY_ eLearning Post Class Survey	Form and Instruction	Unchanged	Indian Health Service (IHS) FY_ eLearning Post Class Survey
216412	Indian Health Service (IHS) FY_ Classroom Post Class Survey	Form and Instruction	Unchanged	Indian Health Service (IHS) FY_ Classroom Post Class Survey
216402	IHS Website Customer Satisfaction Survey – EHR Survey Monkey – VIRTUAL	Form and Instruction	Removed	IHS Website Customer Satisfaction Survey – EHR Survey Monkey – VIRTUAL
216397	IHS Website Customer Satisfaction Survey – EHR Survey Monkey – Classroom Form	Form and Instruction	Removed	IHS Website Customer Satisfaction Survey – EHR Survey Monkey – Classroom Form
216396	Indian Health Service (IHS Website Feedback Form	Form and Instruction	Unchanged	IHS Website Customer Satisfaction Survey - First Page
216396	Indian Health Service (IHS Website Feedback Form	Form and Instruction	Unchanged	IHS Website Feedback Form

ICR Details

OMB Control No: 0917-0036	ICR Reference No: 201804-0917-001
Status: Historical Active	Previous ICR Reference No: 201504-0917-007
Agency/Subagency: HHS/IHS	Agency Tracking No: 1
Title: Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: IHS Customer Service Satisfaction and Similar Surveys
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/30/2019
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/12/2018
Terms of Clearance: OMB approves this collection for a period of three years. To request approval of information collections under this generic approval, the agency must do the following: 1) Unless an agency is using multiple modes of collection (e.g., paper forms and electronic submissions), provide a Generic Clearance Submission Template for each Instrument; 2) If the agency is using multiple modes of collection (e.g., paper forms and electronic submissions), the same Generic Clearance Submission Template may be used for both instruments; 3) each Generic Clearance Submission Template must be uploaded as a Supplementary document using a naming convention that allows the public to identify the associated instrument; 4) submit no more than five Generic Submission Templates with each request.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2022	36 Months From Approved	02/28/2019
Responses	105,000	0	105,000
Time Burden (Hours)	17,500	0	17,500
Cost Burden (Dollars)	0	0	0

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Abstract: This fast track generic collection of information is neccesssary to enable IHS to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improving service delivery. The information collected from our customers and stakeholders will help ensure that users have an effective, efficient, and satisfying experience with the Agency's programs.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: SETTING CUSTOMER SERVICE STANDARDS
   US Code: 44 USC 3501 Name of Law: Paperwork Reduction Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 45034	09/27/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 56833	11/30/2017
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 62

table that charts list of burden

IC Title	Form No.	Form Name
Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit (CSU)	0917-0036	Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit
Anticoagulation Clinic Patient Satisfaction Survey	0917-0036	Anticoagulation Clinic Patient Satisfaction Survey
Catawba Service Unit Patient Satisfaction Survey	0917-0036	Catawba Service Unit Patient Satisfaction Survey
Chinle Service Unit (CSU) Employee Satisfaction Survey.	0917-0036	CSU Employee Survey 2015
Clinical Decision Support Usability Assessment	0917-0036	Clinical Decision Support Usability Assessment
Computer Based Post Class Survey	0917-0036	Computer Based Training (CBT)Post Class Survey
Confer Satisfaction Survey	0917-0036-86	Confer Satisfaction Survey
Dental Professionals & Human Papillomavirus (HPV) Prevention Survey	9017-0036	HPV Survey
Diabetes Care Survey	0917-0036	Diabetes Care Survey
EHR Pharmacy Residence Informaticists Survey	0917-0036	EHR Pharmacy Residence Informaticists Survey
Employee Assessment- Clinton Service Unit - IMPRESS	0917-0036	Employee Assessment- Clinton Service Unit - IMPRESS
Evaluation Survey of IHS Mandatory Pain and Opioid Training and Prescriber Habits	0917-0036	Evaluation Survey
Fort Washakie Medical Home Patient Feedback	0917-0036	Fort Washakie Medical Home Patient Feedback
Gallup Service Unit Patient Satisfaction Survey	0917-0036	Gallup Service Unit Patient Satisfaction Survey
Health Promotion Disease Prevention Activities Registration	9017	9017
IHS CHR NET Plenary Evaluation Form	0917-0036	IHS CHR NET Plenary Evaluation Form
IHS Chinle Service Unit Customer Experience Survey	0917-0036, 0917-0036	Community Nutrition ,   Gardening Survey
IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition	0917-0036, 0917-0036	Community Nutrition Gardening Survey ,   RDN Services Survey
IHS Community Health Representative Basic Training & Refresher Course Training form	0917-0036	IHS Community Health Representative Basic Training & Refresher Course Training form
IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey	9017-0036	IHS CHR Survey
IHS OEHE Customer Satisfaction Forms	0917-0036, 0917-0036, 0917-0036, 0917-0036	Annual Operator O & M Survey ,   Post-Construction O & M Survey ,   Tribal Homeowner Survey ,   Tribal Partner Survey
IHS Patient Experience Survey	0917-0036	IHS Patient Experience Survey
IHS Pharmacy Automation 2015 Survey	0917-0036	IHS Pharmacy Automation 2015 Survey
IHS RPMS Annual Training Needs Assessment Survey	0917-0036	IHS RPMS Annual Training Needs Assessment Survey
IHS RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment	0917-0036	Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment
IHS Training Needs Survey	0917-0036-23	Training Needs Survey
IHS Web Services Customer Satisfaction Survey	IHS Web Services Customer Feedback	IHS Web Services Customer Feedback
IHS Website Customer Satisfaction Survey – EHR Survey Monkey – Classroom Form	0917-0036	IHS Website Customer Satisfaction Survey – EHR Survey Monkey – Classroom Form
IHS Website Customer Satisfaction Survey – EHR Survey Monkey – VIRTUAL	0917-0036	IHS Website Customer Satisfaction Survey – EHR Survey Monkey – VIRTUAL
IHS Website ICD-10 Stakeholder Readiness Survey – ICD-10 Project Needs Assessment	0917-0036	IHS Website ICD-10 Stakeholder Readiness Survey – ICD-10 Project Needs Assessment
IHS White Earth Hand Washing Survey	0917-0036	Hand Washing Survey
Indian Health Service (IHS Website Feedback Form	0917-0036, 0917-0036	IHS Website Feedback Form ,   IHS Website Customer Satisfaction Survey - First Page
Indian Health Service (IHS) Clinical Rounds Qualitative Feedback	0917-0036	Indian Health Service (IHS) Clinical Rounds Qualitative Feedback
Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation	0917-0036	Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation
Indian Health Service (IHS) FY_ Classroom Post Class Survey	0917-0036	Indian Health Service (IHS) FY_ Classroom Post Class Survey
Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey	0917-0036, 0917-0036	Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey ,   FY___Satellite Classroom with Areas Post Class Survey
Indian Health Service (IHS) FY_ eLearning Post Class Survey	0917-0036	Indian Health Service (IHS) FY_ eLearning Post Class Survey
Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey	0917-0036, 0917-0036, 0917-0036	Coordinated Care Survey ,   Patient Registration Suvey ,   Patient Wellness Survey
Indian Health Service National Health Coaching Pilot Project Registration	0917-0036	HCW Application
Innovative Session Partnership Conference
Laboratory Training Evaluation	0917-0036	Lab Survey
Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey	87, 87-1	MAT Provider Survey ,   PrEP Questionnaire
OIT Customer Satisfaction Survey – Problem Ticket	0917-0036, 0917-0036	OIT Customer Satisfaction Survey – Problem Ticket ,   OIT Customer Satisfaction Survey – Problem Ticket (screen shot)
OIT Customer Satisfaction Survey-Service Ticket	0917-0036, 0917-0036	OIT Customer Satisfaction Survey-Service Ticket ,   OIT Customer Satisfaction Survey-Service Ticket (screen shot)
OIT RPMS Training Needs Assessment Survey	0917-0036	FY21 OIT RPMS Training Needs Assessment Survey
OIT RPMS Training Post Class Survey	0916-0036, 0917-0036	ELearning Survey ,   Classroom Survey
OMB Form No. 0917-0036, Indian Health Service (IHS) Community Health Representative (CHR) Basic Online Training Evaluation	0917-0036	IHS CHR Basic Online Training Evaluation
OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036	Wellness Center Survey ,   Adolescent School Health ,   Community Nutrition Survey ,   Diabetes Survey ,   Health Promotion Survey ,   Native Medicine Survey ,   Public Health Nursing - for Patient Care Giver - Survey ,   Public Health Nursing - for Patient
Obstetric Care Unit (OCU) Patient Experience Survey, Chinle Service Unit	0917-0036	Obstetrical Care Unit (OCU) Patient Experience Suvey, Chinle Service Unit (CSU)
PT/OT (Therapy Department) - Provision of Care Survey	0917-0036	PT/OT (Therapy Department) - Provision of Care Survey
Patient Assessment –Clinton Service Unit - IMPRESS	0917-0036	Patient Assessment –Clinton Service Unit - IMPRESS
Patient Experience Surveys - White Earth Service Unit	0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036	Dental Survey ,   Lab Dept Survey ,   Optometry Survey ,   Radiology Dept Survey ,   Therapist Survey
Patient Experience of Care Survey Pilot Project	0917-0036	Patient Experience of Care Survey
Patient Flow Time Study	0917-0036	Patient Flow Time Study
Patient Satisfaction Survey - Crownpoint Service Unit	9017-0036	Patient Survey
Patient Satisfaction Survey, Alburquerque Service Unit	0917-0036	Patient Satisfaction Survey, Alburquerque Service Unit
Patient Satisfaction Survey, Crow Service Unit	0917-0036	Patient Satisfaction Survey, Crow Service Unit
Patient Satisfaction Survey, Optometry Dept. White Earth Service Unit Indian Health Service	0917-0036-12	Patient Satisfaction Survey for the White Earth Optometry Dept.
Patient Satisfaction Survey, Tohatchi	0917-0036	Patient Satisfaction Survey, Tohatchi
Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)	0917-0036	Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)
Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit (CSU)	0917-0036	Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit CSU)
Physician/Dentist Customer Service Questionnaire	0917-0036	Physician/Dentist Customer Service Questionnaire
Portland Area Division of Environment Health Services: Customer Service Assessment.	0917-0036	Portland Area Division of Environment Health Services: Customer Service Assessment.
Providers –e-RX Deployment Survey	0917-0036	Providers - e-RX Deployment Survey
Public Health Nursing Data Mart Survey	0917-0036	Public Health Nursing (PHN) Data Mart Survey Questions
Special Care Unit (SCU) Patient Experience Survey, Chinle Service Unit	0917-0036	Special Care Unit (SCU) Patient Experience Survey
Sugar Shockers Health Campaign Survey, Catawba Service Unit	0917-0036	Sugar Shockers Health Campaign Survey, Catawba Service Unit
THC Dental Patient Satisfaction Survey	0917-0036	THC Dental Patient Satisfaction Survey
Tele-Behavioral Health Center of Excellence (TBHCE) Survey	9017-0036	LHP Behaviorial Health Training Needs Survey
Telebehavioral Health Patient Satisfaction Survey	0917-0036	Telebehavioral Health Patient Satisfaction Survey
User satisfaction data collection for the IHS OIT NDW	0917-0036	Indian Health Service, Office of Information Technology, National Patient Reporting System National Data Warehouse Data Collection Survey
VPN User Survey	0917-0036	VPN User Survey
WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	1, 2, 3, 4, 5, 6, 7, 8	Behavioral Health Patient Satisfaction Survey ,   Dental Patient Satisfaction Survey ,   Laboratory Patient Satisfaction Survey ,   Nutrition Services Patient Satisfaction Survey ,   Optometry Patient Satisfaction Survey ,   Pharmacy Patient Satisfaction Survey ,   Physcial Therapy Patient Satisfaction Survey ,   Radiology Patient Satisfaction Survey
We Care Survey, Blackfeet Community Hospital.	0917-0036	We Care Survey, Blackfeet Community Hospital.
We Care Survey, Fort Peck Service Unit Indian Health Service	0917-0036	We Care Survey, Fort Peck Service Unit Indian Health Service
We Care Survey, Fort Peck Service Unit Indian Health Service	0917-0036	We Care Survey, Fort Peck Service Unit, Indian Health Service
We Care Survey, Northern Cheyenne	0917-0036	We Care Patient Satisfaction Survey for Northern Cheyenne
WebTMA Survey	0917-0036	WebTMA Survey
White Earth Dental Clinic Patient Satisfaction Survey	0917-0036	White Earth Dental Clinic Patient Satisfaction Survey
Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey	0917-0036	Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey
eLearning Hands-on Customer Satisfaction Survey	0917-0036	eLearning Hands-on Customer Satisfaction survey

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	105,000	105,000	0	0	0	0
Annual Time Burden (Hours)	17,500	17,500	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $25,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/12/2018

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