Information Collection

Physician/Dentist Customer Service Questionnaire

IC 216426 under ICR 202201-0917-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Physician/Dentist Customer Service Questionnaire	Form and Instruction
Form 0917-0036 Physician/Dentist Customer Service Questionnaire Physician/Dentist Customer Service Questionnaire	Form and Instruction
0917-0036 Physician/Dentist Customer Service Questionnaire OMB No. 0917-0036-12, Physician & Dentist Customer Service Questionnaire - 2015.docx	Form and Instruction
0917-0036 Physician/Dentist Customer Service Questionnaire OMB No. 0917-0036-12, Physician & Dentist Customer Service Questionnaire - 2015.docx	Form and Instruction
OMB No. 0917-0036-12 Mini Supporting Statement - 2015.doc OMB No. 0917-0036, Mini-Supporting Statement for Physician/Dentist Customer Service Questionnaire	IC Document
OMB No. 0917-0036-12 Mini Supporting Statement - 2015.doc OMB No. 0917-0036, Mini-Supporting Statement for Physician/Dentist Customer Service Questionnaire	IC Document

IC Title:

Physician/Dentist Customer Service Questionnaire

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	Physician/Dentist Customer Service Questionnaire	OMB No. 0917-0036-12, Physician & Dentist Customer Service Questionnaire - 2015.docx		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

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	500	500
Annual IC Time Burden (Hours)	42	42
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 Physician/Dentist Customer Service Questionnaire	OMB No. 0917-0036-12 Mini Supporting Statement - 2015.doc	05/05/2015

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