Information Collection

White Earth Dental Clinic Patient Satisfaction Survey

IC 216512 under ICR 201804-0917-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 White Earth Dental Clinic Patient Satisfaction Survey	Form and Instruction
0917-0036 White Earth Dental Clinic Patient Satisfaction Survey OMB No. 0917-0036, Revised Dental Patient Satisfaction Survey 03042015.docx	Form and Instruction
OMB No 0917-0036-34 Mini-Supporting Statement for Dental Patient Satisfaction Survey.doc OMB No. 0917-0036, Mini-Supporting Statement for White Earth Dental Clinic Patient Satisfaction Survey	IC Document

IC Title:

White Earth Dental Clinic Patient Satisfaction Survey

Agency IC Tracking Number:

IC Status: Unchanged

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	White Earth Dental Clinic Patient Satisfaction Survey	OMB No. 0917-0036, Revised Dental Patient Satisfaction Survey 03042015.docx		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 420

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	Previously Approved
Annual Number of Responses for this IC	420	420
Annual IC Time Burden (Hours)	21	21
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 White Earth Dental Clinic Patient Satisfaction Survey	OMB No 0917-0036-34 Mini-Supporting Statement for 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.