Information Collection

Chinle Mobile Health Unit (MHU) Customer Satisfaction and Needs Survey

IC 268495 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⚠️ Notice: This information collection may be referencing outdated material.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 0917-0036-163 Chinle Mobile Health Unit (MHU) Customer Satisfaction and Needs Survey Chinle Mobile Health Unit (MHU) Customer Satisfaction and Needs Survey	Form and Instruction
0917-0036-163 Chinle Mobile Health Unit (MHU) Customer Satisfaction an Chinle SU MHU patient satisfaction survey HQ comments_AF revisions 6.11.24.docx	Form and Instruction
Chinle SU Mobile Health Unit Survey submission 5-2024.docx Submission Template - MHU	IC Document

IC Title:

Chinle Mobile Health Unit (MHU) Customer Satisfaction and Needs Survey

Agency IC Tracking Number:

163

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	0917-0036-163				No		Paper 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
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Submission Template - MHU		06/12/2024

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

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