Northern Arizona Dental Service survey

Clearance for A-11 Section 280 Improving Customer Experience Information Collection

Documents and Forms

Document Name Document Type
Form Northern Arizona D Northern Arizona Dental Service survey Form and Instruction
Form Northern Arizona D Northern Arizona Dental Service survey Form and Instruction
Northern Arizona D Northern Arizona Dental Service survey Dental Survey Wireframe.docx Form and Instruction
Northern Arizona D Northern Arizona Dental Service survey Dental Survey Wireframe.docx Form and Instruction
ICR Template_A11 Section 280 Clearance.pdf Northern Arizona Dental Service survey IC Document
ICR Template_A11 Section 280 Clearance.pdf Northern Arizona Dental Service survey IC Document

Information Collection (IC) Details

IC Title:	Northern Arizona Dental Service survey	Agency IC Tracking Number:	2900-0876 Dental

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	Northern Arizona Dental Service survey	Northern Arizona Dental Service survey	Dental Survey Wireframe.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	60	60
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Northern Arizona Dental Service survey	ICR Template_A11 Section 280 Clearance.pdf	05/09/2023

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