Information Collection

Patient Satisfaction Survey, Crow Service Unit

IC 216564 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⚠️ Notice: This information collection may be referencing outdated material.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 Patient Satisfaction Survey, Crow Service Unit	Form and Instruction
0917-0036 Patient Satisfaction Survey, Crow Service Unit OMB 0917-0036 Sugar Shocker Health Campaign Survey at Catawaba SU.docx	Form and Instruction
0917-0036- Mini-Supporting Statement for Sugar Shocker Health Campaign Survey at Catawaba SU.doc OMB No. 0917-0036, Mini-Supporting Statement for Patient Satisfaction Survey, Crow Service Unit	IC Document

IC Title:

Patient Satisfaction Survey, Crow Service Unit

Agency IC Tracking Number:

IC Status: Removed

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 Satisfaction Survey, Crow Service Unit	OMB 0917-0036 Sugar Shocker Health Campaign Survey at Catawaba SU.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 720

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-720	720
Annual IC Time Burden (Hours)	-60	60
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 Patient Satisfaction Survey, Crow Service Unit	0917-0036- Mini-Supporting Statement for Sugar Shocker Health Campaign Survey at Catawaba SU.doc	05/12/2015

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