Information Collection

Fort Washakie Medical Home Patient Feedback

IC 229103 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⚠️ Notice: This information collection may be referencing outdated material.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 Fort Washakie Medical Home Patient Feedback	Form and Instruction
0917-0036 Fort Washakie Medical Home Patient Feedback PATSAT2017-PHR -.doc	Form and Instruction
2015 Generic Clearance Submission Fort Washakie Survey.doc 2015 Generic Clearance Submission Fort Washakie Survey	IC Document

IC Title:

Fort Washakie Medical Home Patient Feedback

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	Fort Washakie Medical Home Patient Feedback	PATSAT2017-PHR -.doc		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 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	200	200
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
2015 Generic Clearance Submission Fort Washakie Survey	2015 Generic Clearance Submission Fort Washakie Survey.doc	11/21/2017

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