Information Collection

Patient Experience Surveys - White Earth Service Unit

IC 237875 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⚠️ Notice: This information collection may be referencing outdated material.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 Experience Surveys - White Earth Service Unit	Form and Instruction
0917-0036 Dental Survey Dental Survey Update 04232019.docx	Form and Instruction
0917-0036 Lab Dept Survey Lab Department Survey_Edit 04232019.docx	Form and Instruction
0917-0036 Optometry Survey Optometry Survey Update 04232019.docx	Form and Instruction
0917-0036 Radiology Dept Survey Radiology Department Survey_Edit 04232019.docx	Form and Instruction
0917-0036 Therapist Survey Therapist Survey.docx	Form and Instruction
2015 Generic Clearance Submission Template - IHS (002).doc Submission Template White Earth Surveys	IC Document

IC Title:

Patient Experience Surveys - White Earth Service Unit

Agency IC Tracking Number:

IC Status: New

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?	Electronic Capability
Form and Instruction	0917-0036	Dental Survey	Dental Survey Update 04232019.docx	No	Paper Only
Form and Instruction	0917-0036	Lab Dept Survey	Lab Department Survey_Edit 04232019.docx	No	Paper Only
Form and Instruction	0917-0036	Optometry Survey	Optometry Survey Update 04232019.docx	No	Paper Only
Form and Instruction	0917-0036	Radiology Dept Survey	Radiology Department Survey_Edit 04232019.docx	No	Paper Only
Form and Instruction	0917-0036	Therapist Survey	Therapist Survey.docx	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 800

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	67	67
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Submission Template White Earth Surveys	2015 Generic Clearance Submission Template - IHS (002).doc	09/25/2019

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