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) Unchanged 1200 120 0 Form and Instruction 0917-0036 Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit
Anticoagulation Clinic Patient Satisfaction Survey New 15 2 0 Form and Instruction 0917-0036 Anticoagulation Clinic Patient Satisfaction Survey
Catawba Service Unit Patient Satisfaction Survey Unchanged 360 30 0 Form and Instruction 0917-0036 Catawba Service Unit Patient Satisfaction Survey
Chinle Service Unit (CSU) Employee Satisfaction Survey. Unchanged 2400 240 0 Form and Instruction 0917-0036 CSU Employee Survey 2015
Clinical Decision Support Usability Assessment Unchanged 400 33 0 Form and Instruction 0917-0036 Clinical Decision Support Usability Assessment
Computer Based Post Class Survey Unchanged 2500 208 0 Form and Instruction 0917-0036 Computer Based Training (CBT)Post Class Survey
Confer Satisfaction Survey New 41 1 0 Form 0917-0036-86 Confer Satisfaction Survey
Dental Professionals & Human Papillomavirus (HPV) Prevention Survey New 500 92 0 Form and Instruction 9017-0036 HPV Survey
Diabetes Care Survey New 40 3 0 Form and Instruction 0917-0036 Diabetes Care Survey
EHR Pharmacy Residence Informaticists Survey Removed 0 0 0 Form and Instruction 0917-0036 EHR Pharmacy Residence Informaticists Survey
Employee Assessment- Clinton Service Unit - IMPRESS Unchanged 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 Unchanged 125 21 0 Form and Instruction 0917-0036 Evaluation Survey
Fort Washakie Medical Home Patient Feedback Unchanged 200 33 0 Form and Instruction 0917-0036 Fort Washakie Medical Home Patient Feedback
Gallup Service Unit Patient Satisfaction Survey Removed 0 0 0 Form and Instruction 0917-0036 Gallup Service Unit Patient Satisfaction Survey
Health Promotion Disease Prevention Activities Registration New 120 10 0 Form and Instruction 9017 9017
IHS CHR NET Plenary Evaluation Form Unchanged 325 27 0 Form and Instruction 0917-0036 IHS CHR NET Plenary Evaluation Form
IHS Chinle Service Unit Customer Experience Survey New 1800 90 0 Form and Instruction 0917-0036 Community Nutrition
Form and Instruction 0917-0036 Gardening Survey
IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition Unchanged 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 Removed 0 0 0 Form and Instruction 0917-0036 IHS Community Health Representative Basic Training & Refresher Course Training form
IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey New 325 108 0 Form and Instruction 9017-0036 IHS CHR Survey
IHS OEHE Customer Satisfaction Forms Removed 0 0 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 Unchanged 40 3 0 Form and Instruction 0917-0036 IHS Patient Experience Survey
IHS Pharmacy Automation 2015 Survey Unchanged 200 33 0 Form and Instruction 0917-0036 IHS Pharmacy Automation 2015 Survey
IHS RPMS Annual Training Needs Assessment Survey Removed 0 0 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 Unchanged 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 Unchanged 950 238 0 Form and Instruction 0917-0036-23 Training Needs Survey
IHS Web Services Customer Satisfaction Survey Unchanged 600 49 0 Form IHS Web Services Customer Feedback IHS Web Services Customer Feedback
IHS Website Customer Satisfaction Survey – EHR Survey Monkey – Classroom Form Removed 0 0 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 Removed 0 0 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 Removed 0 0 0 Form and Instruction 0917-0036 IHS Website ICD-10 Stakeholder Readiness Survey – ICD-10 Project Needs Assessment
IHS White Earth Hand Washing Survey Unchanged 500 25 0 Form and Instruction 0917-0036 Hand Washing Survey
Indian Health Service (IHS Website Feedback Form Unchanged 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 Unchanged 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 Unchanged 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 Unchanged 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 Unchanged 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 Unchanged 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 Removed 0 0 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
Indian Health Service National Health Coaching Pilot Project Registration New 100 8 0 Form and Instruction 0917-0036 HCW Application
Innovative Session Partnership Conference Unchanged 90 2 0 Other-Discussion Questions
Laboratory Training Evaluation New 35 6 0 Form and Instruction 0917-0036 Lab Survey
Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey New 125 19 0 Form and Instruction 87 MAT Provider Survey
Form and Instruction 87-1 PrEP Questionnaire
OIT Customer Satisfaction Survey – Problem Ticket Unchanged 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 Removed 0 0 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)
OIT RPMS Training Needs Assessment Survey New 727 182 0 Form and Instruction 0917-0036 FY21 OIT RPMS Training Needs Assessment Survey
OIT RPMS Training Post Class Survey New 2000 167 0 Form and Instruction 0916-0036 ELearning Survey
Form and Instruction 0917-0036 Classroom Survey
OMB Form No. 0917-0036, Indian Health Service (IHS) Community Health Representative (CHR) Basic Online Training Evaluation Removed 0 0 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. Unchanged 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 Unchanged 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 Removed 0 0 0 Form and Instruction 0917-0036 PT/OT (Therapy Department) - Provision of Care Survey
Patient Assessment –Clinton Service Unit - IMPRESS Unchanged 500 42 0 Form and Instruction 0917-0036 Patient Assessment –Clinton Service Unit - IMPRESS
Patient Experience Surveys - White Earth Service Unit New 800 67 0 Form and Instruction 0917-0036 Dental Survey
Form and Instruction 0917-0036 Lab Dept Survey
Form and Instruction 0917-0036 Optometry Survey
Form and Instruction 0917-0036 Radiology Dept Survey
Form and Instruction 0917-0036 Therapist Survey
Patient Experience of Care Survey Pilot Project Unchanged 4000 467 0 Form and Instruction 0917-0036 Patient Experience of Care Survey
Patient Flow Time Study Unchanged 540 45 0 Form and Instruction 0917-0036 Patient Flow Time Study
Patient Satisfaction Survey - Crownpoint Service Unit New 500 83 0 Form and Instruction 9017-0036 Patient Survey
Patient Satisfaction Survey, Alburquerque Service Unit Unchanged 600 20 0 Form and Instruction 0917-0036 Patient Satisfaction Survey, Alburquerque Service Unit
Patient Satisfaction Survey, Crow Service Unit Removed 0 0 0 Form and Instruction 0917-0036 Patient Satisfaction Survey, Crow Service Unit
Patient Satisfaction Survey, Optometry Dept. White Earth Service Unit Indian Health Service Unchanged 200 10 0 Form and Instruction 0917-0036-12 Patient Satisfaction Survey for the White Earth Optometry Dept.
Patient Satisfaction Survey, Tohatchi Removed 0 0 0 Form and Instruction 0917-0036 Patient Satisfaction Survey, Tohatchi
Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC) Unchanged 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) Unchanged 420 42 0 Form and Instruction 0917-0036 Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit CSU)
Physician/Dentist Customer Service Questionnaire Unchanged 500 42 0 Form and Instruction 0917-0036 Physician/Dentist Customer Service Questionnaire
Portland Area Division of Environment Health Services: Customer Service Assessment. Removed 0 0 0 Form and Instruction 0917-0036 Portland Area Division of Environment Health Services: Customer Service Assessment.
Providers –e-RX Deployment Survey Removed 0 0 0 Form and Instruction 0917-0036 Providers - e-RX Deployment Survey
Public Health Nursing Data Mart Survey Unchanged 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 Unchanged 360 36 0 Form and Instruction 0917-0036 Special Care Unit (SCU) Patient Experience Survey
Sugar Shockers Health Campaign Survey, Catawba Service Unit Removed 0 0 0 Form and Instruction 0917-0036 Sugar Shockers Health Campaign Survey, Catawba Service Unit
THC Dental Patient Satisfaction Survey Removed 0 0 0 Form and Instruction 0917-0036 THC Dental Patient Satisfaction Survey
Tele-Behavioral Health Center of Excellence (TBHCE) Survey New 300 50 0 Form and Instruction 9017-0036 LHP Behaviorial Health Training Needs Survey
Telebehavioral Health Patient Satisfaction Survey Unchanged 40 3 0 Form 0917-0036 Telebehavioral Health Patient Satisfaction Survey
User satisfaction data collection for the IHS OIT NDW Unchanged 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 Removed 0 0 0 Form and Instruction 0917-0036 VPN User Survey
WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys New 960 80 0 Form and Instruction 1 Behavioral Health Patient Satisfaction Survey
Form and Instruction 2 Dental Patient Satisfaction Survey
Form and Instruction 3 Laboratory Patient Satisfaction Survey
Form and Instruction 4 Nutrition Services Patient Satisfaction Survey
Form and Instruction 5 Optometry Patient Satisfaction Survey
Form and Instruction 6 Pharmacy Patient Satisfaction Survey
Form and Instruction 7 Physcial Therapy Patient Satisfaction Survey
Form and Instruction 8 Radiology Patient Satisfaction Survey
We Care Survey, Blackfeet Community Hospital. Unchanged 1200 100 0 Form and Instruction 0917-0036 We Care Survey, Blackfeet Community Hospital.
We Care Survey, Fort Peck Service Unit Indian Health Service Unchanged 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 Unchanged 1800 90 0 Form and Instruction 0917-0036 We Care Survey, Fort Peck Service Unit, Indian Health Service
We Care Survey, Northern Cheyenne Unchanged 720 60 0 Form and Instruction 0917-0036 We Care Patient Satisfaction Survey for Northern Cheyenne
WebTMA Survey Unchanged 75 13 0 Form and Instruction 0917-0036 WebTMA Survey
White Earth Dental Clinic Patient Satisfaction Survey Unchanged 420 21 0 Form and Instruction 0917-0036 White Earth Dental Clinic Patient Satisfaction Survey
Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey New 50 4 0 Form and Instruction 0917-0036 Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey
eLearning Hands-on Customer Satisfaction Survey Unchanged 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: 60243 5135 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
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