Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit (CSU) New 1200 120 0 Form and Instruction 0917-0036 Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit
Catawba Service Unit Patient Satisfaction Survey New 360 30 0 Form and Instruction 0917-0036 Catawba Service Unit Patient Satisfaction Survey
Chinle Service Unit (CSU) Employee Satisfaction Survey. New 2400 240 0 Form and Instruction 0917-0036 CSU Employee Survey 2015
Chinle Service Unit (CSU) Health Promotion/Disease Prevention New 2400 120 0 Form and Instruction 0917-0036-58-3 CSU Health Promotion survey
Clinical Decision Support Usability Assessment New 400 33 0 Form and Instruction 0917-0036 Clinical Decision Support Usability Assessment
Computer Based Post Class Survey New 2500 208 0 Form and Instruction 0917-0036 Computer Based Training (CBT)Post Class Survey
EHR Pharmacy Residence Informaticists Survey New 34 3 0 Form and Instruction 0917-0036 EHR Pharmacy Residence Informaticists Survey
Employee Assessment- Clinton Service Unit - IMPRESS New 500 42 0 Form and Instruction 0917-0036 Employee Assessment- Clinton Service Unit - IMPRESS
Evaluation Survey of IHS Mandatory Pain and Opioid Training and Prescriber Habits New 125 21 0 Form and Instruction 0917-0036 Evaluation Survey
Fort Washakie Medical Home Patient Feedback New 200 33 0 Form and Instruction 0917-0036 Fort Washakie Medical Home Patient Feedback
Gallup Service Unit Patient Satisfaction Survey New 2800 233 0 Form and Instruction 0917-0036 Gallup Service Unit Patient Satisfaction Survey
IHS CHR NET Plenary Evaluation Form New 325 27 0 Form and Instruction 0917-0036 IHS CHR NET Plenary Evaluation Form
IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition New 1800 90 0 Form 0917-0036 Community Nutrition Gardening Survey
Form 0917-0036 RDN Services Survey
IHS Community Health Representative Basic Training & Refresher Course Training form New 180 15 0 Form and Instruction 0917-0036 IHS Community Health Representative Basic Training & Refresher Course Training form
IHS OEHE Customer Satisfaction Forms New 1800 90 0 Form and Instruction 0917-0036 Annual Operator O & M Survey
Form and Instruction 0917-0036 Post-Construction O & M Survey
Form and Instruction 0917-0036 Tribal Homeowner Survey
Form and Instruction 0917-0036 Tribal Partner Survey
IHS Patient Experience Survey New 40 3 0 Form and Instruction 0917-0036 IHS Patient Experience Survey
IHS Pharmacy Automation 2015 Survey New 200 33 0 Form and Instruction 0917-0036 IHS Pharmacy Automation 2015 Survey
IHS RPMS Annual Training Needs Assessment Survey New 550 92 0 Form and Instruction 0917-0036 IHS RPMS Annual Training Needs Assessment Survey
IHS RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment New 500 83 0 Form and Instruction 0917-0036 Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment
IHS Training Needs Survey New 950 238 0 Form and Instruction 0917-0036-23 Training Needs Survey
IHS Web Services Customer Satisfaction Survey New 600 49 0 Form IHS Web Services Customer Feedback IHS Web Services Customer Feedback
IHS Website Customer Satisfaction Survey – EHR Survey Monkey – Classroom Form New 500 83 0 Form and Instruction 0917-0036 IHS Website Customer Satisfaction Survey – EHR Survey Monkey – Classroom Form
IHS Website Customer Satisfaction Survey – EHR Survey Monkey – VIRTUAL New 500 83 0 Form and Instruction 0917-0036 IHS Website Customer Satisfaction Survey – EHR Survey Monkey – VIRTUAL
IHS Website ICD-10 Stakeholder Readiness Survey – ICD-10 Project Needs Assessment New 2000 333 0 Form and Instruction 0917-0036 IHS Website ICD-10 Stakeholder Readiness Survey – ICD-10 Project Needs Assessment
IHS White Earth Hand Washing Survey New 500 25 0 Form and Instruction 0917-0036 Hand Washing Survey
Indian Health Service (IHS Website Feedback Form New 500 125 0 Form and Instruction 0917-0036 IHS Website Feedback Form
Form and Instruction 0917-0036 IHS Website Customer Satisfaction Survey - First Page
Indian Health Service (IHS) Clinical Rounds Qualitative Feedback New 500 83 0 Form and Instruction 0917-0036 Indian Health Service (IHS) Clinical Rounds Qualitative Feedback
Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation New 110 9 0 Form and Instruction 0917-0036 Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation
Indian Health Service (IHS) FY_ Classroom Post Class Survey New 1000 83 0 Form and Instruction 0917-0036 Indian Health Service (IHS) FY_ Classroom Post Class Survey
Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey New 500 42 0 Form and Instruction 0917-0036 Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey
Form and Instruction 0917-0036 FY___Satellite Classroom with Areas Post Class Survey
Indian Health Service (IHS) FY_ eLearning Post Class Survey New 2500 208 0 Form and Instruction 0917-0036 Indian Health Service (IHS) FY_ eLearning Post Class Survey
Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey New 1800 150 0 Form and Instruction 0917-0036 Coordinated Care Survey
Form and Instruction 0917-0036 Patient Registration Suvey
Form and Instruction 0917-0036 Patient Wellness Survey
Innovative Session Partnership Conference New 90 2 0 Other-Discussion Questions
OIT Customer Satisfaction Survey – Problem Ticket New 500 42 0 Form and Instruction 0917-0036 OIT Customer Satisfaction Survey – Problem Ticket
Form and Instruction 0917-0036 OIT Customer Satisfaction Survey – Problem Ticket (screen shot)
OIT Customer Satisfaction Survey-Service Ticket New 500 42 0 Form and Instruction 0917-0036 OIT Customer Satisfaction Survey-Service Ticket
Form and Instruction 0917-0036 OIT Customer Satisfaction Survey-Service Ticket (screen shot)
OMB Form No. 0917-0036, Indian Health Service (IHS) Community Health Representative (CHR) Basic Online Training Evaluation New 300 25 0 Form and Instruction 0917-0036 IHS CHR Basic Online Training Evaluation
OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health. New 16200 810 0 Form and Instruction 0917-0036 Wellness Center Survey
Form and Instruction 0917-0036 Adolescent School Health
Form and Instruction 0917-0036 Community Nutrition Survey
Form and Instruction 0917-0036 Diabetes Survey
Form and Instruction 0917-0036 Health Promotion Survey
Form and Instruction 0917-0036 Native Medicine Survey
Form and Instruction 0917-0036 Public Health Nursing - for Patient Care Giver - Survey
Form and Instruction 0917-0036 Public Health Nursing - for Patient
Obstetric Care Unit (OCU) Patient Experience Survey, Chinle Service Unit New 480 48 0 Form and Instruction 0917-0036 Obstetrical Care Unit (OCU) Patient Experience Suvey, Chinle Service Unit (CSU)
PT/OT (Therapy Department) - Provision of Care Survey New 350 18 0 Form and Instruction 0917-0036 PT/OT (Therapy Department) - Provision of Care Survey
Patient Assessment –Clinton Service Unit - IMPRESS New 500 42 0 Form and Instruction 0917-0036 Patient Assessment –Clinton Service Unit - IMPRESS
Patient Experience of Care Survey Pilot Project New 4000 467 0 Form and Instruction 0917-0036 Patient Experience of Care Survey
Patient Flow Time Study New 540 45 0 Form and Instruction 0917-0036 Patient Flow Time Study
Patient Satisfaction Survey, Alburquerque Service Unit New 600 20 0 Form and Instruction 0917-0036 Patient Satisfaction Survey, Alburquerque Service Unit
Patient Satisfaction Survey, Crow Service Unit New 720 60 0 Form and Instruction 0917-0036 Patient Satisfaction Survey, Crow Service Unit
Patient Satisfaction Survey, Optometry Dept. White Earth Service Unit Indian Health Service New 200 10 0 Form and Instruction 0917-0036-12 Patient Satisfaction Survey for the White Earth Optometry Dept.
Patient Satisfaction Survey, Tohatchi New 360 30 0 Form and Instruction 0917-0036 Patient Satisfaction Survey, Tohatchi
Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC) New 540 45 0 Form and Instruction 0917-0036 Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)
Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit (CSU) New 420 42 0 Form and Instruction 0917-0036 Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit CSU)
Physician/Dentist Customer Service Questionnaire New 500 42 0 Form and Instruction 0917-0036 Physician/Dentist Customer Service Questionnaire
Portland Area Division of Environment Health Services: Customer Service Assessment. New 60 15 0 Form and Instruction 0917-0036 Portland Area Division of Environment Health Services: Customer Service Assessment.
Providers –e-RX Deployment Survey New 300 25 0 Form and Instruction 0917-0036 Providers - e-RX Deployment Survey
Public Health Nursing Data Mart Survey New 123 21 0 Form and Instruction 0917-0036 Public Health Nursing (PHN) Data Mart Survey Questions
Special Care Unit (SCU) Patient Experience Survey, Chinle Service Unit New 360 36 0 Form and Instruction 0917-0036 Special Care Unit (SCU) Patient Experience Survey
Sugar Shockers Health Campaign Survey, Catawba Service Unit New 200 17 0 Form and Instruction 0917-0036 Sugar Shockers Health Campaign Survey, Catawba Service Unit
THC Dental Patient Satisfaction Survey New 360 30 0 Form and Instruction 0917-0036 THC Dental Patient Satisfaction Survey
Telebehavioral Health Patient Satisfaction Survey New 40 3 0 Form 0917-0036 Telebehavioral Health Patient Satisfaction Survey
User satisfaction data collection for the IHS OIT NDW New 487 81 0 Form and Instruction 0917-0036 Indian Health Service, Office of Information Technology, National Patient Reporting System National Data Warehouse Data Collection Survey
VPN User Survey New 220 18 0 Form and Instruction 0917-0036 VPN User Survey
We Care Survey, Blackfeet Community Hospital. New 1200 100 0 Form and Instruction 0917-0036 We Care Survey, Blackfeet Community Hospital.
We Care Survey, Fort Peck Service Unit Indian Health Service New 1800 90 0 Form and Instruction 0917-0036 We Care Survey, Fort Peck Service Unit, Indian Health Service
We Care Survey, Fort Peck Service Unit Indian Health Service New 1800 90 0 Form and Instruction 0917-0036 We Care Survey, Fort Peck Service Unit Indian Health Service
We Care Survey, Northern Cheyenne New 720 60 0 Form and Instruction 0917-0036 We Care Patient Satisfaction Survey for Northern Cheyenne
WebTMA Survey New 75 13 0 Form and Instruction 0917-0036 WebTMA Survey
White Earth Dental Clinic Patient Satisfaction Survey New 420 21 0 Form and Instruction 0917-0036 White Earth Dental Clinic Patient Satisfaction Survey
eLearning Hands-on Customer Satisfaction Survey New 2500 208 0 Form and Instruction 0917-0036 eLearning Hands-on Customer Satisfaction survey
Total Burden Actually Used for Information Collections Under Currently Approved ICR: 67739 5645 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
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