Information Collection

Patient Experience of Care Survey Pilot Project

IC 224877 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⚠️ Notice: This information collection may be referencing outdated material.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 Patient Experience of Care Survey Pilot Project	Form and Instruction
0917-0036 Patient Experience of Care Survey SURVEY PREVIEW MODE IHS Pilot Survey Final.docx	Form and Instruction
0917-0036 Patient Experience of Care Survey SURVEY PREVIEW MODE IHS Pilot Survey Final.docx	Form and Instruction
12.7.2016_Brochure_IHSPatient Experience of Care Survey.docx Patient Experience of Care Brochure	IC Document
12.7.2016_Brochure_IHSPatient Experience of Care Survey.docx Patient Experience of Care Brochure	IC Document
IHS_Patient Exp Script12.9.2016.docx Patient Experience of Care Script	IC Document
IHS_Patient Exp Script12.9.2016.docx Patient Experience of Care Script	IC Document
12 12 2016 OMB IHS Patient Exp of Care.doc Request for Approval - Patient Experience of Care Survey Pilot Project	IC Document
12 12 2016 OMB IHS Patient Exp of Care.doc Request for Approval - Patient Experience of Care Survey Pilot Project	IC Document

IC Title:

Patient Experience of Care Survey Pilot Project

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	Patient Experience of Care Survey	SURVEY PREVIEW MODE IHS Pilot Survey Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,000

Number of Respondents for Small Entity: 1,000

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	467	467
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Patient Experience of Care Brochure	12.7.2016_Brochure_IHSPatient Experience of Care Survey.docx	12/22/2016
Patient Experience of Care Script	IHS_Patient Exp Script12.9.2016.docx	12/22/2016
Request for Approval - Patient Experience of Care Survey Pilot Project	12 12 2016 OMB IHS Patient Exp of Care.doc	12/22/2016

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