Information Collection

Patient Satisfaction Survey - Crownpoint Service Unit

IC 250077 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⚠️ Notice: This information collection may be referencing outdated material.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 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

IC Title:

Patient Satisfaction Survey - Crownpoint 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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.