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
Anticoagulation Clinic Patient Satisfaction Survey New 15 2 0 Form and Instruction 0917-0036
Catawba Service Unit Patient Satisfaction Survey Unchanged 360 30 0 Form and Instruction 0917-0036
Chinle Service Unit (CSU) Employee Satisfaction Survey. Unchanged 2400 240 0 Form and Instruction 0917-0036
Clinical Decision Support Usability Assessment Unchanged 400 33 0 Form and Instruction 0917-0036
Computer Based Post Class Survey Unchanged 2500 208 0 Form and Instruction 0917-0036
Confer Satisfaction Survey New 41 1 0 Form 0917-0036-86
Dental Professionals & Human Papillomavirus (HPV) Prevention Survey New 500 92 0 Form and Instruction 9017-0036
Diabetes Care Survey New 40 3 0 Form and Instruction 0917-0036
EHR Pharmacy Residence Informaticists Survey Removed 0 0 0 Form and Instruction 0917-0036
Employee Assessment- Clinton Service Unit - IMPRESS Unchanged 500 42 0 Form and Instruction 0917-0036
Evaluation Survey of IHS Mandatory Pain and Opioid Training and Prescriber Habits Unchanged 125 21 0 Form and Instruction 0917-0036
Fort Washakie Medical Home Patient Feedback Unchanged 200 33 0 Form and Instruction 0917-0036
Gallup Service Unit Patient Satisfaction Survey Removed 0 0 0 Form and Instruction 0917-0036
Health Promotion Disease Prevention Activities Registration New 120 10 0 Form and Instruction 9017
IHS CHR NET Plenary Evaluation Form Unchanged 325 27 0 Form and Instruction 0917-0036
IHS Chinle Service Unit Customer Experience Survey New 1800 90 0 Form and Instruction 0917-0036
Form and Instruction 0917-0036
IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition Unchanged 1800 90 0 Form 0917-0036
Form 0917-0036
IHS Community Health Representative Basic Training & Refresher Course Training form Removed 0 0 0 Form and Instruction 0917-0036
IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey New 325 108 0 Form and Instruction 9017-0036
IHS OEHE Customer Satisfaction Forms Removed 0 0 0 Form and Instruction 0917-0036
Form and Instruction 0917-0036
Form and Instruction 0917-0036
Form and Instruction 0917-0036
IHS Patient Experience Survey Unchanged 40 3 0 Form and Instruction 0917-0036
IHS Pharmacy Automation 2015 Survey Unchanged 200 33 0 Form and Instruction 0917-0036
IHS RPMS Annual Training Needs Assessment Survey Removed 0 0 0 Form and Instruction 0917-0036
IHS RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment Unchanged 500 83 0 Form and Instruction 0917-0036
IHS Training Needs Survey Unchanged 950 238 0 Form and Instruction 0917-0036-23
IHS Web Services Customer Satisfaction Survey Unchanged 600 49 0 Form 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 – VIRTUAL Removed 0 0 0 Form and Instruction 0917-0036
IHS Website ICD-10 Stakeholder Readiness Survey – ICD-10 Project Needs Assessment Removed 0 0 0 Form and Instruction 0917-0036
IHS White Earth Hand Washing Survey Unchanged 500 25 0 Form and Instruction 0917-0036
Indian Health Service (IHS Website Feedback Form Unchanged 500 125 0 Form and Instruction 0917-0036
Form and Instruction 0917-0036
Indian Health Service (IHS) Clinical Rounds Qualitative Feedback Unchanged 500 83 0 Form and Instruction 0917-0036
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) FY_ Classroom Post Class Survey Unchanged 1000 83 0 Form and Instruction 0917-0036
Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey Unchanged 500 42 0 Form and Instruction 0917-0036
Form and Instruction 0917-0036
Indian Health Service (IHS) FY_ eLearning Post Class Survey Unchanged 2500 208 0 Form and Instruction 0917-0036
Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey Removed 0 0 0 Form and Instruction 0917-0036
Form and Instruction 0917-0036
Form and Instruction 0917-0036
Indian Health Service National Health Coaching Pilot Project Registration New 100 8 0 Form and Instruction 0917-0036
Innovative Session Partnership Conference Unchanged 90 2 0 Other-Discussion Questions
Laboratory Training Evaluation New 35 6 0 Form and Instruction 0917-0036
Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey New 125 19 0 Form and Instruction 87
Form and Instruction 87-1
OIT Customer Satisfaction Survey – Problem Ticket Unchanged 500 42 0 Form and Instruction 0917-0036
Form and Instruction 0917-0036
OIT Customer Satisfaction Survey-Service Ticket Removed 0 0 0 Form and Instruction 0917-0036
Form and Instruction 0917-0036
OIT RPMS Training Needs Assessment Survey New 727 182 0 Form and Instruction 0917-0036
OIT RPMS Training Post Class Survey New 2000 167 0 Form and Instruction 0916-0036
Form and Instruction 0917-0036
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
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
Form and Instruction 0917-0036
Form and Instruction 0917-0036
Form and Instruction 0917-0036
Form and Instruction 0917-0036
Form and Instruction 0917-0036
Form and Instruction 0917-0036
Form and Instruction 0917-0036
Obstetric Care Unit (OCU) Patient Experience Survey, Chinle Service Unit Unchanged 480 48 0 Form and Instruction 0917-0036
PT/OT (Therapy Department) - Provision of Care Survey Removed 0 0 0 Form and Instruction 0917-0036
Patient Assessment –Clinton Service Unit - IMPRESS Unchanged 500 42 0 Form and Instruction 0917-0036
Patient Experience Surveys - White Earth Service Unit New 800 67 0 Form and Instruction 0917-0036
Form and Instruction 0917-0036
Form and Instruction 0917-0036
Form and Instruction 0917-0036
Form and Instruction 0917-0036
Patient Experience of Care Survey Pilot Project Unchanged 4000 467 0 Form and Instruction 0917-0036
Patient Flow Time Study Unchanged 540 45 0 Form and Instruction 0917-0036
Patient Satisfaction Survey - Crownpoint Service Unit New 500 83 0 Form and Instruction 9017-0036
Patient Satisfaction Survey, Alburquerque Service Unit Unchanged 600 20 0 Form and Instruction 0917-0036
Patient Satisfaction Survey, Crow Service Unit Removed 0 0 0 Form and Instruction 0917-0036
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, Tohatchi Removed 0 0 0 Form and Instruction 0917-0036
Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC) Unchanged 540 45 0 Form and Instruction 0917-0036
Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit (CSU) Unchanged 420 42 0 Form and Instruction 0917-0036
Physician/Dentist Customer Service Questionnaire Unchanged 500 42 0 Form and Instruction 0917-0036
Portland Area Division of Environment Health Services: Customer Service Assessment. Removed 0 0 0 Form and Instruction 0917-0036
Providers –e-RX Deployment Survey Removed 0 0 0 Form and Instruction 0917-0036
Public Health Nursing Data Mart Survey Unchanged 123 21 0 Form and Instruction 0917-0036
Special Care Unit (SCU) Patient Experience Survey, Chinle Service Unit Unchanged 360 36 0 Form and Instruction 0917-0036
Sugar Shockers Health Campaign Survey, Catawba Service Unit Removed 0 0 0 Form and Instruction 0917-0036
THC Dental Patient Satisfaction Survey Removed 0 0 0 Form and Instruction 0917-0036
Tele-Behavioral Health Center of Excellence (TBHCE) Survey New 300 50 0 Form and Instruction 9017-0036
Telebehavioral Health Patient Satisfaction Survey Unchanged 40 3 0 Form 0917-0036
User satisfaction data collection for the IHS OIT NDW Unchanged 487 81 0 Form and Instruction 0917-0036
VPN User Survey Removed 0 0 0 Form and Instruction 0917-0036
WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys New 960 80 0 Form and Instruction 1
Form and Instruction 2
Form and Instruction 3
Form and Instruction 4
Form and Instruction 5
Form and Instruction 6
Form and Instruction 7
Form and Instruction 8
We Care Survey, Blackfeet Community Hospital. Unchanged 1200 100 0 Form and Instruction 0917-0036
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 Unchanged 1800 90 0 Form and Instruction 0917-0036
We Care Survey, Northern Cheyenne Unchanged 720 60 0 Form and Instruction 0917-0036
WebTMA Survey Unchanged 75 13 0 Form and Instruction 0917-0036
White Earth Dental Clinic Patient Satisfaction Survey Unchanged 420 21 0 Form and Instruction 0917-0036
Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey New 50 4 0 Form and Instruction 0917-0036
eLearning Hands-on Customer Satisfaction Survey Unchanged 2500 208 0 Form and Instruction 0917-0036
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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