Information Collection

Fort Washakie Medical Home Patient Feedback

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⚠️ Notice: This information collection may be referencing outdated material.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