Information Collection

Patient Experience Surveys - White Earth Service Unit

IC 237875 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⚠️ Notice: This information collection may be referencing outdated material.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:

2025-04-30 - Reinstatement without change of a previously approved collection

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
Form 0917-0036 Dental Survey Patient Experience Surveys - White Earth Service Unit	Form and Instruction
Form 0917-0036 Lab Dept Survey Patient Experience Surveys - White Earth Service Unit	Form and Instruction
Form 0917-0036 Optometry Survey Patient Experience Surveys - White Earth Service Unit	Form and Instruction
Form 0917-0036 Radiology Dept Survey Patient Experience Surveys - White Earth Service Unit	Form and Instruction
Form 0917-0036 Therapist Survey Patient Experience Surveys - White Earth Service Unit	Form and Instruction
0917-0036 Dental Survey Dental Survey Update 04232019.docx	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 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 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 Radiology Dept Survey Radiology Department Survey_Edit 04232019.docx	Form and Instruction
0917-0036 Therapist Survey Therapist Survey.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
2015 Generic Clearance Submission Template - IHS (002).doc Submission Template White Earth Surveys	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Patient Experience Surveys - White Earth Service Unit

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	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

Federal Enterprise Architecture Business Reference Module

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
	Requested	Previously Approved
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.