Information Collection

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

IC 218239 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⚠️ Notice: This information collection may be referencing outdated material.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 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: Unchanged

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
	Requested	Previously Approved
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.