Patient Satisfaction Survey - Crownpoint Service Unit

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

Documents and Forms

Document Name Document Type
Form 9017-0036 Patient Satisfaction Survey - Crownpoint Service Unit Form and Instruction
9017-0036 Patient Survey Patient Satisfaction Survey FORM FY2022 Crownpoint Service Unit.docx Form and Instruction
9017-0036 Patient Survey Patient Satisfaction Survey FORM FY2022 Crownpoint Service Unit.docx Form and Instruction
Generic Clearance Submission Template - Patient Survey - Crownpoint.pdf Patient Survey Crownpoint Template IC Document
Generic Clearance Submission Template - Patient Survey - Crownpoint.pdf Patient Survey Crownpoint Template IC Document

Information Collection (IC) Details

IC Title:	Patient Satisfaction Survey - Crownpoint Service Unit	Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	9017-0036	Patient Survey	Patient Satisfaction Survey FORM FY2022 Crownpoint Service Unit.docx		No		Printable Only

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 %

	Requested	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	83	83
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Patient Survey Crownpoint Template	Generic Clearance Submission Template - Patient Survey - Crownpoint.pdf	11/03/2021

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