Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: IHS Customer Service Satisfaction and Similar Surveys

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0917-0036-163 Chinle Mobile Health Unit (MHU) Customer Satisfaction and Needs Survey	Form and Instruction	New	Repair queued
Form 162 Health IT Modernization Program Awareness Survey	Form and Instruction	New	Repair queued
Form 0917-0036-160 IHS TEC Focus Group	Form and Instruction	New	Repair queued
Form 0917-0036-160 IHS TEC Key Informant Interviews	Form and Instruction	New	Repair queued
Form 0917-0036-160 TEC Survey Questionnaire	Form and Instruction	New	Repair queued
Form 0917-0036-149 Four Corners Regional HC PHN Survey	Form and Instruction	New	Repair queued
Form 0917-0036--164 Suicide Prevention Survey	Form and Instruction	New	Repair queued
Form 0917-0036 2024 Health IT Modernization Tribal Consultation/Urban Confer Satisfaction Survey	Form and Instruction	New	Repair queued
Form 0917-0036 Tsaile Health Center DM Patient Survey	Form and Instruction	New	Repair queued
Form 0917-0036 Northern Cheyenne Service Unit Transportation Department	Form and Instruction	New	Repair queued
Form 0917-0036 Naloxone Safety Net Program Worksheet	Form and Instruction	New	Repair queued
Form 0917-0036-141 Turkey Trot	Form and Instruction	New	Repair queued
Form 0917-0036-140 Wellness Survey	Form and Instruction	New	Repair queued
Form 0917-0036-138 Behavioral Health Patient Satisfaction Survey	Form and Instruction	New	Repair queued
Form 0917-0036-0137 DGM Needs Assessment Survey - Staff	Form and Instruction	New	Repair queued
Form 0917-0036-137 DGM Needs Assessment Survey - Recipients	Form and Instruction	New	Repair queued
Form 0917-0036-136 RPMS needs assessment	Form and Instruction	New	Repair queued
Form 0917-0036-135 JMI	Form and Instruction	New	Repair queued
Form 0917-0036-134 Event Survey	Form and Instruction	New	Repair queued
Form 0917-0036-131 DDTP Online Catalog Survey for those that Order Materials	Form and Instruction	New	Repair queued
Form 0917-0036-129 JUST MOVE IT REGISTRATION FORM	Form and Instruction	New	Repair queued
Form 0917-0036-128 Patient Experience of Care Survey	Form and Instruction	New	Repair queued
Form 0917-0036-127 Participant Registration Form for WINGS OF AMERICA RUNNING & FITNESS CAMP	Form and Instruction	New	Repair queued
Form 0917-0036-126 Partnership Survey	Form and Instruction	New	Repair queued
Form 0917-0036-125 General Survey for IHS Division of Diabetes Online Catalog	Form and Instruction	New	Repair queued
Form 0917-0036-125 Afterschool Student Wellness Program – Parent Feedback	Form and Instruction	New	Repair queued
Form 0917-0036-124 OCA Locking Medication Bottle Evaluation Survey	Form and Instruction	New	Repair queued
Form 0917-0036-223 IHS Patient Experience of Care Survey for Telehealth	Form and Instruction	New	Repair queued
Form 0917-0036-122 Telehelath Survey - RingMD	Form and Instruction	New	Repair queued
Form 0917-0036-120b UI Class Survey	Form and Instruction	New	Repair queued
Form 0917-0036-120a PP Physical Therapy Survey	Form and Instruction	New	Repair queued
Form 0917-0036-120 PP Low Back Pelvic Girdle Pain Survey	Form and Instruction	New	Repair queued
Form 0917-0036-121 OUD Survey	Form and Instruction	New	Repair queued
Form 0917-0036-110 PHCI	Form and Instruction	New	Repair queued
Form 0917-0036-109 Registration	Form and Instruction	New	Repair queued
Form 0917-0036-102 Survey Now	Form and Instruction	New	Repair queued
Form 0917-0036-101 Registration	Form and Instruction	New	Repair queued
Form 0917-0036-110 MASU survey	Form and Instruction	New	Repair queued
Form 0917-0036-109 Wings Registration Form	Form and Instruction	New	Repair queued
Form 0917-0036-110 Needs Assessment Survey	Form and Instruction	New	Repair queued
Form 0917-0036-109 Pat Registration	Form and Instruction	New	Repair queued
Form 0917-0036-108 JMI Registration Form	Form and Instruction	New	Repair queued
Form 0917-0036-107 OCA Eval	Form and Instruction	New	Repair queued
Form 0917-0036-106 Satisfaction Survey	Form and Instruction	New	Repair queued
Form 0917-0036-105-b Firearm Survey Form	Form	New	Repair queued
Form 0917-00360105-a Firearm Safety Survey	Form and Instruction	New	Repair queued
Form 0917-0036-104 Service Now Surveys	Form and Instruction	New	Repair queued
Form 0917-0036-103 Developing Resilience Survey	Form and Instruction	New	Repair queued
Form 0917-0036-102 CCRT Impact Survey	Form and Instruction	New	Repair queued
Form 0917-0036 Lab Needs Assessment	Form and Instruction	New	Repair queued
Form 0917-0036 TeamSTEPPS	Form and Instruction	New	Repair queued
Form 0917-0036 Community COVID19 Prevention Assessment	Form and Instruction	New	Repair queued
Form 0917-0036 Community Commercial Tobacco Use Survey	Form and Instruction	New	Repair queued
Form 0917-0036 Medical Office Survey	Form and Instruction	New	Repair queued
Form 0917-0036 Hospital Survey	Form and Instruction	New	Repair queued
Form 0917-0036 HCW Application	Form and Instruction	Unchanged	Available
Form 0917-0036 Indian Health Service National Health Coaching Pilot Project Registration	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey	Form and Instruction	Unchanged	Repair queued
Form 9017-0036 Patient Survey	Form and Instruction	Unchanged	Available
Form 9017-0036 Patient Satisfaction Survey - Crownpoint Service Unit	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Classroom Survey	Form and Instruction	Unchanged	Available
Form 0916-0036 ELearning Survey	Form and Instruction	Unchanged	Repair queued
Form 0916-0036 OIT RPMS Training Post Class Survey	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Lab Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Laboratory Training Evaluation	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Anticoagulation Clinic Patient Satisfaction Survey	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Anticoagulation Clinic Patient Satisfaction Survey	Form and Instruction	Unchanged	Repair queued
Form 9017 9017	Form and Instruction	Unchanged	Available
Form 9017 Health Promotion Disease Prevention Activities Registration	Form and Instruction	Unchanged	Repair queued
Form 8 Radiology Patient Satisfaction Survey	Form and Instruction	Unchanged	Available
Form 7 Physcial Therapy Patient Satisfaction Survey	Form and Instruction	Unchanged	Repair queued
Form 6 Pharmacy Patient Satisfaction Survey	Form and Instruction	Unchanged	Available
Form 5 Optometry Patient Satisfaction Survey	Form and Instruction	Unchanged	Available
Form 4 Nutrition Services Patient Satisfaction Survey	Form and Instruction	Unchanged	Available
Form 3 Laboratory Patient Satisfaction Survey	Form and Instruction	Unchanged	Available
Form 2 Dental Patient Satisfaction Survey	Form and Instruction	Unchanged	Available
Form 1 Behavioral Health Patient Satisfaction Survey	Form and Instruction	Unchanged	Available
Form 1 WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	Form and Instruction	Unchanged	Available
Form 0917-0036 FY21 OIT RPMS Training Needs Assessment Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 OIT RPMS Training Needs Assessment Survey	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Therapist Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Radiology Dept Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Optometry Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Lab Dept Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Dental Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Patient Experience Surveys - White Earth Service Unit	Form and Instruction	Unchanged	Missing upstream
Form 0917-0036 Diabetes Care Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Diabetes Care Survey	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Gardening Survey	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Community Nutrition	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 IHS Chinle Service Unit Customer Experience Survey	Form and Instruction	Unchanged	Repair queued
Form 9017-0036 HPV Survey	Form and Instruction	Unchanged	Repair queued
Form 9017-0036 Dental Professionals & Human Papillomavirus (HPV) Prevention Survey	Form and Instruction	Unchanged	Repair queued
Form 9017-0036 LHP Behaviorial Health Training Needs Survey	Form and Instruction	Unchanged	Available
Form 9017-0036 Tele-Behavioral Health Center of Excellence (TBHCE) Survey	Form and Instruction	Unchanged	Missing upstream
Form 87-1 PrEP Questionnaire	Form and Instruction	Unchanged	Available
Form 87 MAT Provider Survey	Form and Instruction	Unchanged	Available
Form 87 Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey	Form and Instruction	Unchanged	Repair queued
Form 0917-0036-86 Confer Satisfaction Survey	Form	Unchanged	Available
Form 0917-0036-86 Confer Satisfaction Survey	Form	Unchanged	Repair queued
Form 9017-0036 IHS CHR Survey	Form and Instruction	Unchanged	Available
Form 9017-0036 IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey	Form and Instruction	Unchanged	Missing upstream
Form 0917-0036 Evaluation Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Evaluation Survey of IHS Mandatory Pain and Opioid Training and Prescriber Habits	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Hand Washing Survey	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 IHS White Earth Hand Washing Survey	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Fort Washakie Medical Home Patient Feedback	Form and Instruction	Unchanged	Available
Form 0917-0036 Fort Washakie Medical Home Patient Feedback	Form and Instruction	Unchanged	Missing upstream
Form 0917-0036-12 Patient Satisfaction Survey for the White Earth Optometry Dept.	Form and Instruction	Unchanged	Available
Form 0917-0036-12 Patient Satisfaction Survey, Optometry Dept. White Earth Service Unit Indian Health Service	Form and Instruction	Unchanged	Repair queued
Form 0917-0036-23 Training Needs Survey	Form and Instruction	Unchanged	Available
Form 0917-0036-23 IHS Training Needs Survey	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 RDN Services Survey	Form	Unchanged	Available
Form 0917-0036 Community Nutrition Gardening Survey	Form	Unchanged	Available
Form 0917-0036 IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition	Form	Unchanged	Available
Form 0917-0036 WebTMA Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 WebTMA Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Telebehavioral Health Patient Satisfaction Survey	Form	Unchanged	Available
Form 0917-0036 Telebehavioral Health Patient Satisfaction Survey	Form	Unchanged	Repair queued
Form 0917-0036 Public Health Nursing (PHN) Data Mart Survey Questions	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Public Health Nursing Data Mart Survey	Form and Instruction	Unchanged	Missing upstream
Form 0917-0036 Patient Experience of Care Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Patient Experience of Care Survey Pilot Project	Form and Instruction	Unchanged	Missing upstream
Form IHS Web Services C IHS Web Services Customer Feedback	Form	Unchanged	Repair queued
Form IHS Web Services C IHS Web Services Customer Satisfaction Survey	Form	Unchanged	Repair queued
Form 0917-0036 Public Health Nursing - for Patient	Form and Instruction	Unchanged	Available
Form 0917-0036 Public Health Nursing - for Patient Care Giver - Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Native Medicine Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Health Promotion Survey	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Diabetes Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Community Nutrition Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Adolescent School Health	Form and Instruction	Unchanged	Available
Form 0917-0036 Wellness Center Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit CSU)	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit (CSU)	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Obstetrical Care Unit (OCU) Patient Experience Suvey, Chinle Service Unit (CSU)	Form and Instruction	Unchanged	Available
Form 0917-0036 Obstetric Care Unit (OCU) Patient Experience Survey, Chinle Service Unit	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Special Care Unit (SCU) Patient Experience Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Special Care Unit (SCU) Patient Experience Survey, Chinle Service Unit	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit	Form and Instruction	Unchanged	Available
Form 0917-0036 Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit (CSU)	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 CSU Employee Survey 2015	Form and Instruction	Unchanged	Available
Form 0917-0036 Chinle Service Unit (CSU) Employee Satisfaction Survey.	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 We Care Survey, Fort Peck Service Unit, Indian Health Service	Form and Instruction	Unchanged	Available
Form 0917-0036 We Care Survey, Fort Peck Service Unit Indian Health Service	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Clinical Decision Support Usability Assessment	Form and Instruction	Unchanged	Available
Form 0917-0036 Clinical Decision Support Usability Assessment	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Indian Health Service, Office of Information Technology, National Patient Reporting System National Data Warehouse Data Collection Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 User satisfaction data collection for the IHS OIT NDW	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 We Care Patient Satisfaction Survey for Northern Cheyenne	Form and Instruction	Unchanged	Available
Form 0917-0036 We Care Survey, Northern Cheyenne	Form and Instruction	Unchanged	Missing upstream
Form 0917-0036 We Care Survey, Blackfeet Community Hospital.	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 We Care Survey, Blackfeet Community Hospital.	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Catawba Service Unit Patient Satisfaction Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Catawba Service Unit Patient Satisfaction Survey	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment	Form and Instruction	Unchanged	Available
Form 0917-0036 IHS RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 We Care Survey, Fort Peck Service Unit Indian Health Service	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 We Care Survey, Fort Peck Service Unit Indian Health Service	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Patient Satisfaction Survey, Alburquerque Service Unit	Form and Instruction	Unchanged	Available
Form 0917-0036 Patient Satisfaction Survey, Alburquerque Service Unit	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 White Earth Dental Clinic Patient Satisfaction Survey	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 White Earth Dental Clinic Patient Satisfaction Survey	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Patient Flow Time Study	Form and Instruction	Unchanged	Available
Form 0917-0036 Patient Flow Time Study	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)	Form and Instruction	Unchanged	Available
Form 0917-0036 Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 eLearning Hands-on Customer Satisfaction survey	Form and Instruction	Unchanged	Available
Form 0917-0036 eLearning Hands-on Customer Satisfaction Survey	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Computer Based Training (CBT)Post Class Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Computer Based Post Class Survey	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 IHS Patient Experience Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 IHS Patient Experience Survey	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 IHS Pharmacy Automation 2015 Survey	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 IHS Pharmacy Automation 2015 Survey	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Indian Health Service (IHS) Clinical Rounds Qualitative Feedback	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Indian Health Service (IHS) Clinical Rounds Qualitative Feedback	Form and Instruction	Unchanged	Missing upstream
Form 0917-0036 IHS CHR NET Plenary Evaluation Form	Form and Instruction	Unchanged	Available
Form 0917-0036 IHS CHR NET Plenary Evaluation Form	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation	Form and Instruction	Unchanged	Available
Form 0917-0036 Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation	Form and Instruction	Unchanged	Available
Form 0917-0036 OIT Customer Satisfaction Survey – Problem Ticket (screen shot)	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 OIT Customer Satisfaction Survey – Problem Ticket	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 OIT Customer Satisfaction Survey – Problem Ticket	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Physician/Dentist Customer Service Questionnaire	Form and Instruction	Unchanged	Available
Form 0917-0036 Physician/Dentist Customer Service Questionnaire	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Patient Assessment –Clinton Service Unit - IMPRESS	Form and Instruction	Unchanged	Available
Form 0917-0036 Patient Assessment –Clinton Service Unit - IMPRESS	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Employee Assessment- Clinton Service Unit - IMPRESS	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Employee Assessment- Clinton Service Unit - IMPRESS	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 FY___Satellite Classroom with Areas Post Class Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Indian Health Service (IHS) FY_ eLearning Post Class Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Indian Health Service (IHS) FY_ eLearning Post Class Survey	Form and Instruction	Unchanged	Repair queued
Form 0917-0036 Indian Health Service (IHS) FY_ Classroom Post Class Survey	Form and Instruction	Unchanged	Available
Form 0917-0036 Indian Health Service (IHS) FY_ Classroom Post Class Survey	Form and Instruction	Unchanged	Missing upstream
Form 0917-0036 IHS Website Customer Satisfaction Survey - First Page	Form and Instruction	Unchanged	Available
Form 0917-0036 IHS Website Feedback Form	Form and Instruction	Unchanged	Available
Form 0917-0036 Indian Health Service (IHS Website Feedback Form	Form and Instruction	Unchanged	Repair queued
Supporting Statement A for OMB No. 0917-0036, IHS Fast Track for Generic Clearance 2022 Final 1.13.22.docx	Supporting Statement A	Uploaded 2022-01-13	Missing upstream
Justification for Burden Increase.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2013-01-18	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
270192	IHS Patient Experience of Care Survey	Other-survey	New
268495	Chinle Mobile Health Unit (MHU) Customer Satisfaction and Needs Survey	Form and Instruction	New	Chinle Mobile Health Unit (MHU) Customer Satisfaction and Needs Survey
268295	Health IT Modernization Program Awareness Survey	Form and Instruction	New	Health IT Modernization Program Awareness Survey
267521	Tribal Epidemiology Centers (TECs) Survey Collection	Form and Instruction	New	IHS TEC Focus Group
267521	Tribal Epidemiology Centers (TECs) Survey Collection	Form and Instruction	New	IHS TEC Key Informant Interviews
267521	Tribal Epidemiology Centers (TECs) Survey Collection	Form and Instruction	New	TEC Survey Questionnaire
267449	Four Corners Regional Health Center Public Health Nursing Patient Satisfaction Survey	Form and Instruction	New	Four Corners Regional HC PHN Survey
267386	Suicide Prevention Conference Survey	Form and Instruction	New	Suicide Prevention Survey
266293	2024 Health IT Modernization Tribal Consultation/Urban Confer Satisfaction Survey	Form and Instruction	New	2024 Health IT Modernization Tribal Consultation/Urban Confer Satisfaction Survey
266151	Tsaile Health Center DM Patient Survey for 2024	Form and Instruction	New	Tsaile Health Center DM Patient Survey
264368	Northern Cheyenne Service Unit Transportation Department	Form and Instruction	New	Northern Cheyenne Service Unit Transportation Department
263886	Naloxone Safety Net Program	Form and Instruction	New	Naloxone Safety Net Program Worksheet
262043	KSU Turkey Trot Registration	Form and Instruction	New	Turkey Trot
262041	CSU Employee Wellness Survey	Form and Instruction	New	Wellness Survey
261581	Patient Satisfaction survey for Behavioral Health Department	Form and Instruction	New	Behavioral Health Patient Satisfaction Survey
261560	IHS Division of Grants Management Needs Assessment Survey	Form and Instruction	New	DGM Needs Assessment Survey - Staff
261560	IHS Division of Grants Management Needs Assessment Survey	Form and Instruction	New	DGM Needs Assessment Survey - Recipients
261177	OIT RPMS Training Needs Assessment	Form and Instruction	New	RPMS needs assessment
260913	JUST MOVE IT REGISTRATION FORM	Form and Instruction	New	JMI
260896	Chinle Event Survey	Form and Instruction	New	Event Survey
260259	IHS Division of Diabetes Treatment and Prevention (DDTP) Online Catalog Survey for those that Order Materials	Form and Instruction	New	DDTP Online Catalog Survey for those that Order Materials
260047	JUST MOVE IT REGISTRATION FORM	Form and Instruction	New	JUST MOVE IT REGISTRATION FORM
259861	Patient Experience of Care Survey	Form and Instruction	New	Patient Experience of Care Survey
259820	Participant Registration Form for WINGS OF AMERICA RUNNING & FITNESS CAMP	Form and Instruction	New	Participant Registration Form for WINGS OF AMERICA RUNNING & FITNESS CAMP
259489	Partnership Survey	Form and Instruction	New	Partnership Survey
259488	General Survey for IHS Division of Diabetes Online Catalog	Form and Instruction	New	General Survey for IHS Division of Diabetes Online Catalog
258764	Afterschool Student Wellness Program – Parent Feedback	Form and Instruction	New	Afterschool Student Wellness Program – Parent Feedback
257468	OCA Locking Medication Bottle Evaluation Survey	Form and Instruction	New	OCA Locking Medication Bottle Evaluation Survey
257007	IHS Patient Experience of Care Survey for Telehealth	Form and Instruction	New	IHS Patient Experience of Care Survey for Telehealth
256559	IHS Provider Survey for Telehealth	Form and Instruction	New	Telehelath Survey - RingMD
256310	Pelvic Health Physical Therapy Surveys	Form and Instruction	New	UI Class Survey
256310	Pelvic Health Physical Therapy Surveys	Form and Instruction	New	PP Physical Therapy Survey
256310	Pelvic Health Physical Therapy Surveys	Form and Instruction	New	PP Low Back Pelvic Girdle Pain Survey
256295	Patient Satisfaction Survey: Response to Opioid Use Disorder (OUD) Treatment	Form and Instruction	New	OUD Survey
256062	Public Health Compliance Initiative (PHCI)	Form and Instruction	New	PHCI
255869	Chinle Wellness Center 7th Annual Half Marathon & 10K	Form and Instruction	New	Registration
254783	Information Technology (IT) Service Management - Service Now Customer Satisfaction Survey	Form and Instruction	New	Survey Now
254782	Attendee Registration Form for the Indian Health Service (IHS) Third Party Billing and Accounts Receivable Training	Form and Instruction	New	Registration
254467	MASU Health Fair Survey	Form and Instruction	New	MASU survey
254465	WINGS OF AMERICA RUNNING & FITNESS CAMP	Form and Instruction	New	Wings Registration Form
254115	OIT RPMS Training Needs Assessment 2022	Form and Instruction	New	Needs Assessment Survey
254105	Registration for the Indian Health Service (IHS) Patient Registration Training	Form and Instruction	New	Pat Registration
253808	Just Move It Registration	Form and Instruction	New	JMI Registration Form
253807	Medication Lock Box Survey	Form and Instruction	New	OCA Eval
253336	Stakeholders Satisfaction Questionnaire	Form and Instruction	New	Satisfaction Survey
253265	Firearm Safety Storage Project	Form	New	Firearm Survey Form
253265	Firearm Safety Storage Project	Form and Instruction	New	Firearm Safety Survey
253264	Information Technology (IT) Service Management - Service Now Customer Satisfaction Survey	Form and Instruction	New	Service Now Surveys
253030	Developing Resilience Survey	Form and Instruction	New	Developing Resilience Survey
253027	National Center for Injury Prevention and Control (NCIPC) Fellows & Interns' Evaluation	Form and Instruction	New	CCRT Impact Survey
252163	Laboratory Needs Assessment	Form and Instruction	New	Lab Needs Assessment
252162	T-TAQ (TeamSTEPPS Teamwork Attitudes Questionnaire)	Form and Instruction	New	TeamSTEPPS
252150	The Community Tobacco Prevention Assessment and Community COVID-19 Prevention Assessment	Form and Instruction	New	Community COVID19 Prevention Assessment
252150	The Community Tobacco Prevention Assessment and Community COVID-19 Prevention Assessment	Form and Instruction	New	Community Commercial Tobacco Use Survey
252144	Indian Health Service Culture of Safety Surveys	Form and Instruction	New	Medical Office Survey
252144	Indian Health Service Culture of Safety Surveys	Form and Instruction	New	Hospital Survey
250384	Indian Health Service National Health Coaching Pilot Project Registration	Form and Instruction	Unchanged	HCW Application
250384	Indian Health Service National Health Coaching Pilot Project Registration	Form and Instruction	Unchanged
250081	Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey	Form and Instruction	Unchanged	Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey
250081	Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey	Form and Instruction	Unchanged
250077	Patient Satisfaction Survey - Crownpoint Service Unit	Form and Instruction	Unchanged	Patient Survey
250077	Patient Satisfaction Survey - Crownpoint Service Unit	Form and Instruction	Unchanged
249370	OIT RPMS Training Post Class Survey	Form and Instruction	Unchanged	Classroom Survey
249370	OIT RPMS Training Post Class Survey	Form and Instruction	Unchanged	ELearning Survey
249370	OIT RPMS Training Post Class Survey	Form and Instruction	Unchanged
249152	Laboratory Training Evaluation	Form and Instruction	Unchanged	Lab Survey
249152	Laboratory Training Evaluation	Form and Instruction	Unchanged
248810	Anticoagulation Clinic Patient Satisfaction Survey	Form and Instruction	Unchanged	Anticoagulation Clinic Patient Satisfaction Survey
248810	Anticoagulation Clinic Patient Satisfaction Survey	Form and Instruction	Unchanged
248668	Health Promotion Disease Prevention Activities Registration	Form and Instruction	Unchanged	9017
248668	Health Promotion Disease Prevention Activities Registration	Form and Instruction	Unchanged
247004	WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	Form and Instruction	Unchanged	Radiology Patient Satisfaction Survey
247004	WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	Form and Instruction	Unchanged	Physcial Therapy Patient Satisfaction Survey
247004	WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	Form and Instruction	Unchanged	Pharmacy Patient Satisfaction Survey
247004	WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	Form and Instruction	Unchanged	Optometry Patient Satisfaction Survey
247004	WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	Form and Instruction	Unchanged	Nutrition Services Patient Satisfaction Survey
247004	WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	Form and Instruction	Unchanged	Laboratory Patient Satisfaction Survey
247004	WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	Form and Instruction	Unchanged	Dental Patient Satisfaction Survey
247004	WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	Form and Instruction	Unchanged	Behavioral Health Patient Satisfaction Survey
247004	WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	Form and Instruction	Unchanged
242056	OIT RPMS Training Needs Assessment Survey	Form and Instruction	Unchanged	FY21 OIT RPMS Training Needs Assessment Survey
242056	OIT RPMS Training Needs Assessment Survey	Form and Instruction	Unchanged
237875	Patient Experience Surveys - White Earth Service Unit	Form and Instruction	Unchanged	Therapist Survey
237875	Patient Experience Surveys - White Earth Service Unit	Form and Instruction	Unchanged	Radiology Dept Survey
237875	Patient Experience Surveys - White Earth Service Unit	Form and Instruction	Unchanged	Optometry Survey
237875	Patient Experience Surveys - White Earth Service Unit	Form and Instruction	Unchanged	Lab Dept Survey
237875	Patient Experience Surveys - White Earth Service Unit	Form and Instruction	Unchanged	Dental Survey
237875	Patient Experience Surveys - White Earth Service Unit	Form and Instruction	Unchanged
237873	Diabetes Care Survey	Form and Instruction	Unchanged	Diabetes Care Survey
237873	Diabetes Care Survey	Form and Instruction	Unchanged
236418	IHS Chinle Service Unit Customer Experience Survey	Form and Instruction	Unchanged	Gardening Survey
236418	IHS Chinle Service Unit Customer Experience Survey	Form and Instruction	Unchanged	Community Nutrition
236418	IHS Chinle Service Unit Customer Experience Survey	Form and Instruction	Unchanged
236413	Dental Professionals & Human Papillomavirus (HPV) Prevention Survey	Form and Instruction	Unchanged	HPV Survey
236413	Dental Professionals & Human Papillomavirus (HPV) Prevention Survey	Form and Instruction	Unchanged
236408	Tele-Behavioral Health Center of Excellence (TBHCE) Survey	Form and Instruction	Unchanged	LHP Behaviorial Health Training Needs Survey
236408	Tele-Behavioral Health Center of Excellence (TBHCE) Survey	Form and Instruction	Unchanged
235443	Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey	Form and Instruction	Unchanged	PrEP Questionnaire
235443	Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey	Form and Instruction	Unchanged	MAT Provider Survey
235443	Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey	Form and Instruction	Unchanged
235441	Confer Satisfaction Survey	Form	Unchanged	Confer Satisfaction Survey
235441	Confer Satisfaction Survey	Form	Unchanged
235243	IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey	Form and Instruction	Unchanged	IHS CHR Survey
235243	IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey	Form and Instruction	Unchanged
230847	Evaluation Survey of IHS Mandatory Pain and Opioid Training and Prescriber Habits	Form and Instruction	Unchanged	Evaluation Survey
230847	Evaluation Survey of IHS Mandatory Pain and Opioid Training and Prescriber Habits	Form and Instruction	Unchanged
230260	IHS White Earth Hand Washing Survey	Form and Instruction	Unchanged	Hand Washing Survey
230260	IHS White Earth Hand Washing Survey	Form and Instruction	Unchanged
229103	Fort Washakie Medical Home Patient Feedback	Form and Instruction	Unchanged	Fort Washakie Medical Home Patient Feedback
229103	Fort Washakie Medical Home Patient Feedback	Form and Instruction	Unchanged
228427	Patient Satisfaction Survey, Optometry Dept. White Earth Service Unit Indian Health Service	Form and Instruction	Unchanged	Patient Satisfaction Survey for the White Earth Optometry Dept.
228427	Patient Satisfaction Survey, Optometry Dept. White Earth Service Unit Indian Health Service	Form and Instruction	Unchanged
227895	Innovative Session Partnership Conference	Other-Discussion Questions	Unchanged
227765	IHS Training Needs Survey	Form and Instruction	Unchanged	Training Needs Survey
227765	IHS Training Needs Survey	Form and Instruction	Unchanged
226315	IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition	Form	Unchanged	RDN Services Survey
226315	IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition	Form	Unchanged	Community Nutrition Gardening Survey
226315	IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition	Form	Unchanged
226049	WebTMA Survey	Form and Instruction	Unchanged	WebTMA Survey
226049	WebTMA Survey	Form and Instruction	Unchanged
225049	Telebehavioral Health Patient Satisfaction Survey	Form	Unchanged	Telebehavioral Health Patient Satisfaction Survey
225049	Telebehavioral Health Patient Satisfaction Survey	Form	Unchanged
225048	Public Health Nursing Data Mart Survey	Form and Instruction	Unchanged	Public Health Nursing (PHN) Data Mart Survey Questions
225048	Public Health Nursing Data Mart Survey	Form and Instruction	Unchanged
224877	Patient Experience of Care Survey Pilot Project	Form and Instruction	Unchanged	Patient Experience of Care Survey
224877	Patient Experience of Care Survey Pilot Project	Form and Instruction	Unchanged
223611	IHS Web Services Customer Satisfaction Survey	Form	Unchanged	IHS Web Services Customer Feedback
223611	IHS Web Services Customer Satisfaction Survey	Form	Unchanged
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	Unchanged	Public Health Nursing - for Patient
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	Unchanged	Public Health Nursing - for Patient Care Giver - Survey
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	Unchanged	Native Medicine Survey
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	Unchanged	Health Promotion Survey
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	Unchanged	Diabetes Survey
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	Unchanged	Community Nutrition Survey
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	Unchanged	Adolescent School Health
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	Unchanged	Wellness Center Survey
218239	OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	Form and Instruction	Unchanged
217933	Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit (CSU)	Form and Instruction	Unchanged	Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit CSU)
217933	Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit (CSU)	Form and Instruction	Unchanged
217932	Obstetric Care Unit (OCU) Patient Experience Survey, Chinle Service Unit	Form and Instruction	Unchanged	Obstetrical Care Unit (OCU) Patient Experience Suvey, Chinle Service Unit (CSU)
217932	Obstetric Care Unit (OCU) Patient Experience Survey, Chinle Service Unit	Form and Instruction	Unchanged
217748	Special Care Unit (SCU) Patient Experience Survey, Chinle Service Unit	Form and Instruction	Unchanged	Special Care Unit (SCU) Patient Experience Survey
217748	Special Care Unit (SCU) Patient Experience Survey, Chinle Service Unit	Form and Instruction	Unchanged
217747	Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit (CSU)	Form and Instruction	Unchanged	Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit
217747	Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit (CSU)	Form and Instruction	Unchanged
217690	Chinle Service Unit (CSU) Employee Satisfaction Survey.	Form and Instruction	Unchanged	CSU Employee Survey 2015
217690	Chinle Service Unit (CSU) Employee Satisfaction Survey.	Form and Instruction	Unchanged
217673	We Care Survey, Fort Peck Service Unit Indian Health Service	Form and Instruction	Unchanged	We Care Survey, Fort Peck Service Unit, Indian Health Service
217673	We Care Survey, Fort Peck Service Unit Indian Health Service	Form and Instruction	Unchanged
216572	Clinical Decision Support Usability Assessment	Form and Instruction	Unchanged	Clinical Decision Support Usability Assessment
216572	Clinical Decision Support Usability Assessment	Form and Instruction	Unchanged
216545	User satisfaction data collection for the IHS OIT NDW	Form and Instruction	Unchanged	Indian Health Service, Office of Information Technology, National Patient Reporting System National Data Warehouse Data Collection Survey
216545	User satisfaction data collection for the IHS OIT NDW	Form and Instruction	Unchanged
216544	We Care Survey, Northern Cheyenne	Form and Instruction	Unchanged	We Care Patient Satisfaction Survey for Northern Cheyenne
216544	We Care Survey, Northern Cheyenne	Form and Instruction	Unchanged
216538	We Care Survey, Blackfeet Community Hospital.	Form and Instruction	Unchanged	We Care Survey, Blackfeet Community Hospital.
216538	We Care Survey, Blackfeet Community Hospital.	Form and Instruction	Unchanged
216532	Catawba Service Unit Patient Satisfaction Survey	Form and Instruction	Unchanged	Catawba Service Unit Patient Satisfaction Survey
216532	Catawba Service Unit Patient Satisfaction Survey	Form and Instruction	Unchanged
216531	IHS RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment	Form and Instruction	Unchanged	Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment
216531	IHS RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment	Form and Instruction	Unchanged
216529	We Care Survey, Fort Peck Service Unit Indian Health Service	Form and Instruction	Unchanged	We Care Survey, Fort Peck Service Unit Indian Health Service
216529	We Care Survey, Fort Peck Service Unit Indian Health Service	Form and Instruction	Unchanged
216514	Patient Satisfaction Survey, Alburquerque Service Unit	Form and Instruction	Unchanged	Patient Satisfaction Survey, Alburquerque Service Unit
216514	Patient Satisfaction Survey, Alburquerque Service Unit	Form and Instruction	Unchanged
216512	White Earth Dental Clinic Patient Satisfaction Survey	Form and Instruction	Unchanged	White Earth Dental Clinic Patient Satisfaction Survey
216512	White Earth Dental Clinic Patient Satisfaction Survey	Form and Instruction	Unchanged
216510	Patient Flow Time Study	Form and Instruction	Unchanged	Patient Flow Time Study
216510	Patient Flow Time Study	Form and Instruction	Unchanged
216509	Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)	Form and Instruction	Unchanged	Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)
216509	Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)	Form and Instruction	Unchanged
216500	eLearning Hands-on Customer Satisfaction Survey	Form and Instruction	Unchanged	eLearning Hands-on Customer Satisfaction survey
216500	eLearning Hands-on Customer Satisfaction Survey	Form and Instruction	Unchanged
216499	Computer Based Post Class Survey	Form and Instruction	Unchanged	Computer Based Training (CBT)Post Class Survey
216499	Computer Based Post Class Survey	Form and Instruction	Unchanged
216493	IHS Patient Experience Survey	Form and Instruction	Unchanged	IHS Patient Experience Survey
216493	IHS Patient Experience Survey	Form and Instruction	Unchanged
216464	IHS Pharmacy Automation 2015 Survey	Form and Instruction	Unchanged	IHS Pharmacy Automation 2015 Survey
216464	IHS Pharmacy Automation 2015 Survey	Form and Instruction	Unchanged
216462	Indian Health Service (IHS) Clinical Rounds Qualitative Feedback	Form and Instruction	Unchanged	Indian Health Service (IHS) Clinical Rounds Qualitative Feedback
216462	Indian Health Service (IHS) Clinical Rounds Qualitative Feedback	Form and Instruction	Unchanged
216457	IHS CHR NET Plenary Evaluation Form	Form and Instruction	Unchanged	IHS CHR NET Plenary Evaluation Form
216457	IHS CHR NET Plenary Evaluation Form	Form and Instruction	Unchanged
216453	Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation	Form and Instruction	Unchanged	Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation
216453	Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation	Form and Instruction	Unchanged
216429	OIT Customer Satisfaction Survey – Problem Ticket	Form and Instruction	Unchanged	OIT Customer Satisfaction Survey – Problem Ticket (screen shot)
216429	OIT Customer Satisfaction Survey – Problem Ticket	Form and Instruction	Unchanged	OIT Customer Satisfaction Survey – Problem Ticket
216429	OIT Customer Satisfaction Survey – Problem Ticket	Form and Instruction	Unchanged
216426	Physician/Dentist Customer Service Questionnaire	Form and Instruction	Unchanged	Physician/Dentist Customer Service Questionnaire
216426	Physician/Dentist Customer Service Questionnaire	Form and Instruction	Unchanged
216424	Patient Assessment –Clinton Service Unit - IMPRESS	Form and Instruction	Unchanged	Patient Assessment –Clinton Service Unit - IMPRESS
216424	Patient Assessment –Clinton Service Unit - IMPRESS	Form and Instruction	Unchanged
216421	Employee Assessment- Clinton Service Unit - IMPRESS	Form and Instruction	Unchanged	Employee Assessment- Clinton Service Unit - IMPRESS
216421	Employee Assessment- Clinton Service Unit - IMPRESS	Form and Instruction	Unchanged
216417	Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey	Form and Instruction	Unchanged	FY___Satellite Classroom with Areas Post Class Survey
216417	Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey	Form and Instruction	Unchanged	Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey
216417	Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey	Form and Instruction	Unchanged
216415	Indian Health Service (IHS) FY_ eLearning Post Class Survey	Form and Instruction	Unchanged	Indian Health Service (IHS) FY_ eLearning Post Class Survey
216415	Indian Health Service (IHS) FY_ eLearning Post Class Survey	Form and Instruction	Unchanged
216412	Indian Health Service (IHS) FY_ Classroom Post Class Survey	Form and Instruction	Unchanged	Indian Health Service (IHS) FY_ Classroom Post Class Survey
216412	Indian Health Service (IHS) FY_ Classroom Post Class Survey	Form and Instruction	Unchanged
216396	Indian Health Service (IHS Website Feedback Form	Form and Instruction	Unchanged	IHS Website Customer Satisfaction Survey - First Page
216396	Indian Health Service (IHS Website Feedback Form	Form and Instruction	Unchanged	IHS Website Feedback Form
216396	Indian Health Service (IHS Website Feedback Form	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0917-0036	ICR Reference No: 202201-0917-001
Status: Historical Active	Previous ICR Reference No: 201804-0917-001
Agency/Subagency: HHS/IHS	Agency Tracking No: 1
Title: Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: IHS Customer Service Satisfaction and Similar Surveys
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/17/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/13/2022
Terms of Clearance: OMB approves this collection for a period of three years. To request approval of information collections under this generic approval, the agency must do the following: 1) Unless an agency is using multiple modes of collection (e.g., paper forms and electronic submissions), provide a Generic Clearance Submission Template for each Instrument; 2) If the agency is using multiple modes of collection (e.g., paper forms and electronic submissions), the same Generic Clearance Submission Template may be used for both instruments; 3) each Generic Clearance Submission Template must be uploaded as a Supplementary document using a naming convention that allows the public to identify the associated instrument; 4) submit no more than five Generic Submission Templates with each request.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2025	36 Months From Approved	02/28/2022
Responses	105,000	0	105,000
Time Burden (Hours)	17,500	0	17,500
Cost Burden (Dollars)	0	0	0

---

Abstract: This fast track generic collection of information is neccesssary to enable IHS to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improving service delivery. The information collected from our customers and stakeholders will help ensure that users have an effective, efficient, and satisfying experience with the Agency's programs.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: SETTING CUSTOMER SERVICE STANDARDS
   US Code: 44 USC 3501 Name of Law: Paperwork Reduction Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 54462	10/01/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 1764	01/12/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 110

table that charts list of burden

IC Title	Form No.	Form Name
Health IT Modernization Program Awareness Survey	162	Health IT Modernization Program Awareness Survey
2024 Health IT Modernization Tribal Consultation/Urban Confer Satisfaction Survey	0917-0036	2024 Health IT Modernization Tribal Consultation/Urban Confer Satisfaction Survey
Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit (CSU)	0917-0036	Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit
Afterschool Student Wellness Program – Parent Feedback	0917-0036-125	Afterschool Student Wellness Program – Parent Feedback
Anticoagulation Clinic Patient Satisfaction Survey	0917-0036	Anticoagulation Clinic Patient Satisfaction Survey
Attendee Registration Form for the Indian Health Service (IHS) Third Party Billing and Accounts Receivable Training	0917-0036-101	Registration
CSU Employee Wellness Survey	0917-0036-140	Wellness Survey
Catawba Service Unit Patient Satisfaction Survey	0917-0036	Catawba Service Unit Patient Satisfaction Survey
Chinle Event Survey	0917-0036-134	Event Survey
Chinle Mobile Health Unit (MHU) Customer Satisfaction and Needs Survey	0917-0036-163	Chinle Mobile Health Unit (MHU) Customer Satisfaction and Needs Survey
Chinle Service Unit (CSU) Employee Satisfaction Survey.	0917-0036	CSU Employee Survey 2015
Chinle Wellness Center 7th Annual Half Marathon & 10K	0917-0036-109	Registration
Clinical Decision Support Usability Assessment	0917-0036	Clinical Decision Support Usability Assessment
Computer Based Post Class Survey	0917-0036	Computer Based Training (CBT)Post Class Survey
Confer Satisfaction Survey	0917-0036-86	Confer Satisfaction Survey
Dental Professionals & Human Papillomavirus (HPV) Prevention Survey	9017-0036	HPV Survey
Developing Resilience Survey	0917-0036-103	Developing Resilience Survey
Diabetes Care Survey	0917-0036	Diabetes Care Survey
Employee Assessment- Clinton Service Unit - IMPRESS	0917-0036	Employee Assessment- Clinton Service Unit - IMPRESS
Evaluation Survey of IHS Mandatory Pain and Opioid Training and Prescriber Habits	0917-0036	Evaluation Survey
Firearm Safety Storage Project	0917-00360105-a, 0917-0036-105-b	Firearm Safety Survey ,   Firearm Survey Form
Fort Washakie Medical Home Patient Feedback	0917-0036	Fort Washakie Medical Home Patient Feedback
Four Corners Regional Health Center Public Health Nursing Patient Satisfaction Survey	0917-0036-149	Four Corners Regional HC PHN Survey
General Survey for IHS Division of Diabetes Online Catalog	0917-0036-125	General Survey for IHS Division of Diabetes Online Catalog
Health Promotion Disease Prevention Activities Registration	9017	9017
IHS CHR NET Plenary Evaluation Form	0917-0036	IHS CHR NET Plenary Evaluation Form
IHS Chinle Service Unit Customer Experience Survey	0917-0036, 0917-0036	Community Nutrition ,   Gardening Survey
IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition	0917-0036, 0917-0036	Community Nutrition Gardening Survey ,   RDN Services Survey
IHS Division of Diabetes Treatment and Prevention (DDTP) Online Catalog Survey for those that Order Materials	0917-0036-131	DDTP Online Catalog Survey for those that Order Materials
IHS Division of Grants Management Needs Assessment Survey	0917-0036-137, 0917-0036-0137	DGM Needs Assessment Survey - Recipients ,   DGM Needs Assessment Survey - Staff
IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey	9017-0036	IHS CHR Survey
IHS Patient Experience Survey	0917-0036	IHS Patient Experience Survey
IHS Patient Experience of Care Survey
IHS Patient Experience of Care Survey for Telehealth	0917-0036-223	IHS Patient Experience of Care Survey for Telehealth
IHS Pharmacy Automation 2015 Survey	0917-0036	IHS Pharmacy Automation 2015 Survey
IHS Provider Survey for Telehealth	0917-0036-122	Telehelath Survey - RingMD
IHS RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment	0917-0036	Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment
IHS Training Needs Survey	0917-0036-23	Training Needs Survey
IHS Web Services Customer Satisfaction Survey	IHS Web Services Customer Feedback	IHS Web Services Customer Feedback
IHS White Earth Hand Washing Survey	0917-0036	Hand Washing Survey
Indian Health Service (IHS Website Feedback Form	0917-0036, 0917-0036	IHS Website Feedback Form ,   IHS Website Customer Satisfaction Survey - First Page
Indian Health Service (IHS) Clinical Rounds Qualitative Feedback	0917-0036	Indian Health Service (IHS) Clinical Rounds Qualitative Feedback
Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation	0917-0036	Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation
Indian Health Service (IHS) FY_ Classroom Post Class Survey	0917-0036	Indian Health Service (IHS) FY_ Classroom Post Class Survey
Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey	0917-0036, 0917-0036	Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey ,   FY___Satellite Classroom with Areas Post Class Survey
Indian Health Service (IHS) FY_ eLearning Post Class Survey	0917-0036	Indian Health Service (IHS) FY_ eLearning Post Class Survey
Indian Health Service Culture of Safety Surveys	0917-0036, 0917-0036	Hospital Survey ,   Medical Office Survey
Indian Health Service National Health Coaching Pilot Project Registration	0917-0036	HCW Application
Information Technology (IT) Service Management - Service Now Customer Satisfaction Survey	0917-0036-104	Service Now Surveys
Information Technology (IT) Service Management - Service Now Customer Satisfaction Survey	0917-0036-102	Survey Now
Innovative Session Partnership Conference
JUST MOVE IT REGISTRATION FORM	0917-0036-129	JUST MOVE IT REGISTRATION FORM
JUST MOVE IT REGISTRATION FORM	0917-0036-135	JMI
Just Move It Registration	0917-0036-108	JMI Registration Form
KSU Turkey Trot Registration	0917-0036-141	Turkey Trot
Laboratory Needs Assessment	0917-0036	Lab Needs Assessment
Laboratory Training Evaluation	0917-0036	Lab Survey
MASU Health Fair Survey	0917-0036-110	MASU survey
Medication Lock Box Survey	0917-0036-107	OCA Eval
Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey	87, 87-1	MAT Provider Survey ,   PrEP Questionnaire
Naloxone Safety Net Program	0917-0036	Naloxone Safety Net Program Worksheet
National Center for Injury Prevention and Control (NCIPC) Fellows & Interns' Evaluation	0917-0036-102	CCRT Impact Survey
Northern Cheyenne Service Unit Transportation Department	0917-0036	Northern Cheyenne Service Unit Transportation Department
OCA Locking Medication Bottle Evaluation Survey	0917-0036-124	OCA Locking Medication Bottle Evaluation Survey
OIT Customer Satisfaction Survey – Problem Ticket	0917-0036, 0917-0036	OIT Customer Satisfaction Survey – Problem Ticket ,   OIT Customer Satisfaction Survey – Problem Ticket (screen shot)
OIT RPMS Training Needs Assessment	0917-0036-136	RPMS needs assessment
OIT RPMS Training Needs Assessment 2022	0917-0036-110	Needs Assessment Survey
OIT RPMS Training Needs Assessment Survey	0917-0036	FY21 OIT RPMS Training Needs Assessment Survey
OIT RPMS Training Post Class Survey	0917-0036, 0916-0036	ELearning Survey ,   Classroom Survey
OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.	0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036	Wellness Center Survey ,   Adolescent School Health ,   Community Nutrition Survey ,   Diabetes Survey ,   Health Promotion Survey ,   Native Medicine Survey ,   Public Health Nursing - for Patient Care Giver - Survey ,   Public Health Nursing - for Patient
Obstetric Care Unit (OCU) Patient Experience Survey, Chinle Service Unit	0917-0036	Obstetrical Care Unit (OCU) Patient Experience Suvey, Chinle Service Unit (CSU)
Participant Registration Form for WINGS OF AMERICA RUNNING & FITNESS CAMP	0917-0036-127	Participant Registration Form for WINGS OF AMERICA RUNNING & FITNESS CAMP
Partnership Survey	0917-0036-126	Partnership Survey
Patient Assessment –Clinton Service Unit - IMPRESS	0917-0036	Patient Assessment –Clinton Service Unit - IMPRESS
Patient Experience Surveys - White Earth Service Unit	0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036	Dental Survey ,   Lab Dept Survey ,   Optometry Survey ,   Radiology Dept Survey ,   Therapist Survey
Patient Experience of Care Survey	0917-0036-128	Patient Experience of Care Survey
Patient Experience of Care Survey Pilot Project	0917-0036	Patient Experience of Care Survey
Patient Flow Time Study	0917-0036	Patient Flow Time Study
Patient Satisfaction Survey - Crownpoint Service Unit	9017-0036	Patient Survey
Patient Satisfaction Survey, Alburquerque Service Unit	0917-0036	Patient Satisfaction Survey, Alburquerque Service Unit
Patient Satisfaction Survey, Optometry Dept. White Earth Service Unit Indian Health Service	0917-0036-12	Patient Satisfaction Survey for the White Earth Optometry Dept.
Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)	0917-0036	Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)
Patient Satisfaction Survey: Response to Opioid Use Disorder (OUD) Treatment	0917-0036-121	OUD Survey
Patient Satisfaction survey for Behavioral Health Department	0917-0036-138	Behavioral Health Patient Satisfaction Survey
Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit (CSU)	0917-0036	Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit CSU)
Pelvic Health Physical Therapy Surveys	0917-0036-120a, 0917-0036-120b, 0917-0036-120	PP Low Back Pelvic Girdle Pain Survey ,   PP Physical Therapy Survey ,   UI Class Survey
Physician/Dentist Customer Service Questionnaire	0917-0036	Physician/Dentist Customer Service Questionnaire
Public Health Compliance Initiative (PHCI)	0917-0036-110	PHCI
Public Health Nursing Data Mart Survey	0917-0036	Public Health Nursing (PHN) Data Mart Survey Questions
Registration for the Indian Health Service (IHS) Patient Registration Training	0917-0036-109	Pat Registration
Special Care Unit (SCU) Patient Experience Survey, Chinle Service Unit	0917-0036	Special Care Unit (SCU) Patient Experience Survey
Stakeholders Satisfaction Questionnaire	0917-0036-106	Satisfaction Survey
Suicide Prevention Conference Survey	0917-0036--164	Suicide Prevention Survey
T-TAQ (TeamSTEPPS Teamwork Attitudes Questionnaire)	0917-0036	TeamSTEPPS
Tele-Behavioral Health Center of Excellence (TBHCE) Survey	9017-0036	LHP Behaviorial Health Training Needs Survey
Telebehavioral Health Patient Satisfaction Survey	0917-0036	Telebehavioral Health Patient Satisfaction Survey
The Community Tobacco Prevention Assessment and Community COVID-19 Prevention Assessment	0917-0036, 0917-0036	Community Commercial Tobacco Use Survey ,   Community COVID19 Prevention Assessment
Tribal Epidemiology Centers (TECs) Survey Collection	0917-0036-160, 0917-0036-160, 0917-0036-160	TEC Survey Questionnaire ,   IHS TEC Key Informant Interviews ,   IHS TEC Focus Group
Tsaile Health Center DM Patient Survey for 2024	0917-0036	Tsaile Health Center DM Patient Survey
User satisfaction data collection for the IHS OIT NDW	0917-0036	Indian Health Service, Office of Information Technology, National Patient Reporting System National Data Warehouse Data Collection Survey
WINGS OF AMERICA RUNNING & FITNESS CAMP	0917-0036-109	Wings Registration Form
WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	2, 1, 3, 4, 5, 6, 7, 8	Behavioral Health Patient Satisfaction Survey ,   Dental Patient Satisfaction Survey ,   Laboratory Patient Satisfaction Survey ,   Nutrition Services Patient Satisfaction Survey ,   Optometry Patient Satisfaction Survey ,   Pharmacy Patient Satisfaction Survey ,   Physcial Therapy Patient Satisfaction Survey ,   Radiology Patient Satisfaction Survey
We Care Survey, Blackfeet Community Hospital.	0917-0036	We Care Survey, Blackfeet Community Hospital.
We Care Survey, Fort Peck Service Unit Indian Health Service	0917-0036	We Care Survey, Fort Peck Service Unit Indian Health Service
We Care Survey, Fort Peck Service Unit Indian Health Service	0917-0036	We Care Survey, Fort Peck Service Unit, Indian Health Service
We Care Survey, Northern Cheyenne	0917-0036	We Care Patient Satisfaction Survey for Northern Cheyenne
WebTMA Survey	0917-0036	WebTMA Survey
White Earth Dental Clinic Patient Satisfaction Survey	0917-0036	White Earth Dental Clinic Patient Satisfaction Survey
Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey	0917-0036	Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey
eLearning Hands-on Customer Satisfaction Survey	0917-0036	eLearning Hands-on Customer Satisfaction survey

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	105,000	105,000	0	0	0	0
Annual Time Burden (Hours)	17,500	17,500	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $25,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/13/2022

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