Information Collection

Four Corners Regional Health Center Public Health Nursing Patient Satisfaction Survey

IC 267449 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⚠️ Notice: This information collection may be referencing outdated material.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 0917-0036-149 Four Corners Regional HC PHN Survey Four Corners Regional Health Center Public Health Nursing Patient Satisfaction Survey	Form and Instruction
0917-0036-149 Four Corners Regional HC PHN Survey Four Corners Regional HC PHN Customer Services Survey response from 4CRHC 3.27.24.docx	Form and Instruction
Four Corners Regional HC PHN Generic Clearance Submission response from 4CRHC 3.27.24.docx Submission Template - FCRH Survey	IC Document

IC Title:

Four Corners Regional Health Center Public Health Nursing Patient Satisfaction Survey

Agency IC Tracking Number:

149

IC Status: New

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	0917-0036-149				No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Submission Template - FCRH Survey		05/03/2024

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

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