Information Collection

Indian Health Service Purchased/Referred Care Patient Experience Survey

IC 273436 under ICR 202411-0990-001 · OMB 0990-0491.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 PRC Patient Feedback Survey Indian Health Service Purchased/Referred Care Patient Experience Survey	Form
1 PRC Patient Feedback Survey PRC Patient Survey_Final_12.23.24.docx	Form
ICR Template_A11 Section 280 Clearance_IHS PRC v1_PRC Survey_12.23.24.docx ICR Template_A11 Section 280 Clearance_IHS PRCv1_Survey	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 5 CFR CFR 1320.5(b). (To search for a specific CFR, visit the Code of Federal Regulations.)

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	1				No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,000

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	10,000	10,000
Annual IC Time Burden (Hours)	3,000	3,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ICR Template_A11 Section 280 Clearance_IHS PRCv1_Survey		12/27/2024

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

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