Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: IHS Customer Service Satisfaction and Similar Surveys

OMB 0917-0036

This fast track generic collection of information is neccesssary to enable IHS to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improving service delivery. The information collected from our customers and stakeholders will help ensure that users have an effective, efficient, and satisfying experience with the Agency's programs.

The latest form for Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: IHS Customer Service Satisfaction and Similar Surveys expires 2022-01-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 0917-0036 Indian Health Service National Health Coaching Pilot Project Registration Form and Instruction
Form 0917-0036 Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey Form and Instruction
Form 9017-0036 Patient Satisfaction Survey - Crownpoint Service Unit Form and Instruction
Form 0916-0036 OIT RPMS Training Post Class Survey Form and Instruction
Form 0917-0036 Laboratory Training Evaluation Form and Instruction
Form 0917-0036 Anticoagulation Clinic Patient Satisfaction Survey Form and Instruction
Form 9017 Health Promotion Disease Prevention Activities Registration Form and Instruction
Form 1 WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys Form and Instruction
Form 0917-0036 OIT RPMS Training Needs Assessment Survey Form and Instruction
Form 0917-0036 Patient Experience Surveys - White Earth Service Unit Form and Instruction
Form 0917-0036 Diabetes Care Survey Form and Instruction
Form 0917-0036 IHS Chinle Service Unit Customer Experience Survey Form and Instruction
Form 9017-0036 Dental Professionals & Human Papillomavirus (HPV) Prevention Survey Form and Instruction
Form 9017-0036 Tele-Behavioral Health Center of Excellence (TBHCE) Survey Form and Instruction
Form 87 Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey Form and Instruction
Form 0917-0036-86 Confer Satisfaction Survey Form
Form 9017-0036 IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey Form and Instruction
Form 0917-0036 Evaluation Survey of IHS Mandatory Pain and Opioid Training and Prescriber Habits Form and Instruction
Form 0917-0036 IHS White Earth Hand Washing Survey Form and Instruction
Form 0917-0036 Fort Washakie Medical Home Patient Feedback Form and Instruction
Form 0917-0036-12 Patient Satisfaction Survey, Optometry Dept. White Earth Service Unit Indian Health Service Form and Instruction
Form 0917-0036-23 IHS Training Needs Survey Form and Instruction
Form 0917-0036 IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition Form
Form 0917-0036 WebTMA Survey Form and Instruction
Form 0917-0036 Telebehavioral Health Patient Satisfaction Survey Form
Form 0917-0036 Public Health Nursing Data Mart Survey Form and Instruction
Form 0917-0036 Patient Experience of Care Survey Pilot Project Form and Instruction
Form IHS Web Services C IHS Web Services Customer Satisfaction Survey Form
Form 0917-0036 OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health. Form and Instruction
Form 0917-0036 Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit (CSU) Form and Instruction
Form 0917-0036 Obstetric Care Unit (OCU) Patient Experience Survey, Chinle Service Unit Form and Instruction
Form 0917-0036 Special Care Unit (SCU) Patient Experience Survey, Chinle Service Unit Form and Instruction
Form 0917-0036 Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit (CSU) Form and Instruction
Form 0917-0036 Chinle Service Unit (CSU) Employee Satisfaction Survey. Form and Instruction
Form 0917-0036 We Care Survey, Fort Peck Service Unit Indian Health Service Form and Instruction
Form 0917-0036 Clinical Decision Support Usability Assessment Form and Instruction
Form 0917-0036 User satisfaction data collection for the IHS OIT NDW Form and Instruction
Form 0917-0036 We Care Survey, Northern Cheyenne Form and Instruction
Form 0917-0036 We Care Survey, Blackfeet Community Hospital. Form and Instruction
Form 0917-0036 Catawba Service Unit Patient Satisfaction Survey Form and Instruction
Form 0917-0036 IHS RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment Form and Instruction
Form 0917-0036 We Care Survey, Fort Peck Service Unit Indian Health Service Form and Instruction
Form 0917-0036 Patient Satisfaction Survey, Alburquerque Service Unit Form and Instruction
Form 0917-0036 White Earth Dental Clinic Patient Satisfaction Survey Form and Instruction
Form 0917-0036 Patient Flow Time Study Form and Instruction
Form 0917-0036 Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC) Form and Instruction
Form 0917-0036 eLearning Hands-on Customer Satisfaction Survey Form and Instruction
Form 0917-0036 Computer Based Post Class Survey Form and Instruction
Form 0917-0036 IHS Patient Experience Survey Form and Instruction
Form 0917-0036 IHS Pharmacy Automation 2015 Survey Form and Instruction
Form 0917-0036 Indian Health Service (IHS) Clinical Rounds Qualitative Feedback Form and Instruction
Form 0917-0036 IHS CHR NET Plenary Evaluation Form Form and Instruction
Form 0917-0036 Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation Form and Instruction
Form 0917-0036 OIT Customer Satisfaction Survey – Problem Ticket Form and Instruction
Form 0917-0036 Physician/Dentist Customer Service Questionnaire Form and Instruction
Form 0917-0036 Patient Assessment –Clinton Service Unit - IMPRESS Form and Instruction
Form 0917-0036 Employee Assessment- Clinton Service Unit - IMPRESS Form and Instruction
Form 0917-0036 Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey Form and Instruction
Form 0917-0036 Indian Health Service (IHS) FY_ eLearning Post Class Survey Form and Instruction
Form 0917-0036 Indian Health Service (IHS) FY_ Classroom Post Class Survey Form and Instruction
Form 0917-0036 Indian Health Service (IHS Website Feedback Form Form and Instruction
Supporting Statement A for OMB No. 0917-0036, IHS Fast Track for Generic Clearance 2022 Final 1.13.22.docx Supporting Statement A
Justification for Burden Increase.docx Justification for No Material/Nonsubstantive Change
Indian Health Service National Health Coaching Pilot Project Registration Form and Instruction
Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey Form and Instruction
Patient Satisfaction Survey - Crownpoint Service Unit Form and Instruction
OIT RPMS Training Post Class Survey Form and Instruction
Laboratory Training Evaluation Form and Instruction
Anticoagulation Clinic Patient Satisfaction Survey Form and Instruction
Health Promotion Disease Prevention Activities Registration Form and Instruction
WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys Form and Instruction
OIT RPMS Training Needs Assessment Survey Form and Instruction
Patient Experience Surveys - White Earth Service Unit Form and Instruction
Diabetes Care Survey Form and Instruction
IHS Chinle Service Unit Customer Experience Survey Form and Instruction
Dental Professionals & Human Papillomavirus (HPV) Prevention Survey Form and Instruction
Tele-Behavioral Health Center of Excellence (TBHCE) Survey Form and Instruction
Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey Form and Instruction
Confer Satisfaction Survey Form
IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey Form and Instruction
Evaluation Survey of IHS Mandatory Pain and Opioid Training and Prescriber Habits Form and Instruction
IHS White Earth Hand Washing Survey Form and Instruction
Fort Washakie Medical Home Patient Feedback Form and Instruction
Patient Satisfaction Survey, Optometry Dept. White Earth Service Unit Indian Health Service Form and Instruction
Innovative Session Partnership Conference Other-Discussion Questions
IHS Training Needs Survey Form and Instruction
IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition Form
WebTMA Survey Form and Instruction
Telebehavioral Health Patient Satisfaction Survey Form
Public Health Nursing Data Mart Survey Form and Instruction
Patient Experience of Care Survey Pilot Project Form and Instruction
IHS Web Services Customer Satisfaction Survey Form
OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health. Form and Instruction
Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit (CSU) Form and Instruction
Obstetric Care Unit (OCU) Patient Experience Survey, Chinle Service Unit Form and Instruction
Special Care Unit (SCU) Patient Experience Survey, Chinle Service Unit Form and Instruction
Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit (CSU) Form and Instruction
Chinle Service Unit (CSU) Employee Satisfaction Survey. Form and Instruction
We Care Survey, Fort Peck Service Unit Indian Health Service Form and Instruction
Clinical Decision Support Usability Assessment Form and Instruction
User satisfaction data collection for the IHS OIT NDW Form and Instruction
We Care Survey, Northern Cheyenne Form and Instruction
We Care Survey, Blackfeet Community Hospital. Form and Instruction
Catawba Service Unit Patient Satisfaction Survey Form and Instruction
IHS RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment Form and Instruction
We Care Survey, Fort Peck Service Unit Indian Health Service Form and Instruction
Patient Satisfaction Survey, Alburquerque Service Unit Form and Instruction
White Earth Dental Clinic Patient Satisfaction Survey Form and Instruction
Patient Flow Time Study Form and Instruction
Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC) Form and Instruction
eLearning Hands-on Customer Satisfaction Survey Form and Instruction
Computer Based Post Class Survey Form and Instruction
IHS Patient Experience Survey Form and Instruction
IHS Pharmacy Automation 2015 Survey Form and Instruction
Indian Health Service (IHS) Clinical Rounds Qualitative Feedback Form and Instruction
IHS CHR NET Plenary Evaluation Form Form and Instruction
Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation Form and Instruction
OIT Customer Satisfaction Survey – Problem Ticket Form and Instruction
Physician/Dentist Customer Service Questionnaire Form and Instruction
Patient Assessment –Clinton Service Unit - IMPRESS Form and Instruction
Employee Assessment- Clinton Service Unit - IMPRESS Form and Instruction
Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey Form and Instruction
Indian Health Service (IHS) FY_ eLearning Post Class Survey Form and Instruction
Indian Health Service (IHS) FY_ Classroom Post Class Survey Form and Instruction
Indian Health Service (IHS Website Feedback Form Form and Instruction

All Historical Document Collections

202201-0917-001 Approved without change	Extension without change of a currently approved collection	2022-01-13
201804-0917-001 Approved without change	Extension without change of a currently approved collection	2018-07-12
201504-0917-007 Approved without change	Extension without change of a currently approved collection	2015-05-13
201301-0917-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2013-01-18
201205-0917-002 Approved with change	New collection (Request for a new OMB Control Number)	2012-05-18
201201-0917-001 Withdrawn	New collection (Request for a new OMB Control Number)	2012-01-25

OMB Details

Indian Health Service (IHS Website Feedback Form

Federal Enterprise Architecture: Health - Health Care Services

Form 0917-0036	IHS Website Feedback Form	www.ihs.gov/feedbackform/	Form and instruction
Form 0917-0036	IHS Website Customer Satisfaction Survey - First Page	Fillable Fileable	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.