Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Health IT Modernization Program Awareness Survey New 1000 83 0 Form and Instruction 162 Health IT Modernization Program Awareness Survey
2024 Health IT Modernization Tribal Consultation/Urban Confer Satisfaction Survey New 300 65 0 Form and Instruction 0917-0036 2024 Health IT Modernization Tribal Consultation/Urban Confer Satisfaction Survey
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
Afterschool Student Wellness Program – Parent Feedback New 80 7 0 Form and Instruction 0917-0036-125 Afterschool Student Wellness Program – Parent Feedback
Anticoagulation Clinic Patient Satisfaction Survey Unchanged 15 2 0 Form and Instruction 0917-0036 Anticoagulation Clinic Patient Satisfaction Survey
Attendee Registration Form for the Indian Health Service (IHS) Third Party Billing and Accounts Receivable Training New 75 6 0 Form and Instruction 0917-0036-101 Registration
CSU Employee Wellness Survey New 500 125 0 Form and Instruction 0917-0036-140 Wellness Survey
Catawba Service Unit Patient Satisfaction Survey Unchanged 360 30 0 Form and Instruction 0917-0036 Catawba Service Unit Patient Satisfaction Survey
Chinle Event Survey New 250 42 0 Form and Instruction 0917-0036-134 Event Survey
Chinle Mobile Health Unit (MHU) Customer Satisfaction and Needs Survey New 500 25 0 Form and Instruction 0917-0036-163 Chinle Mobile Health Unit (MHU) Customer Satisfaction and Needs Survey
Chinle Service Unit (CSU) Employee Satisfaction Survey. Unchanged 2400 240 0 Form and Instruction 0917-0036 CSU Employee Survey 2015
Chinle Wellness Center 7th Annual Half Marathon & 10K New 400 40 0 Form and Instruction 0917-0036-109 Registration
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 Unchanged 41 1 0 Form 0917-0036-86 Confer Satisfaction Survey
Dental Professionals & Human Papillomavirus (HPV) Prevention Survey Unchanged 500 92 0 Form and Instruction 9017-0036 HPV Survey
Developing Resilience Survey New 29 2 0 Form and Instruction 0917-0036-103 Developing Resilience Survey
Diabetes Care Survey Unchanged 40 3 0 Form and Instruction 0917-0036 Diabetes Care 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
Firearm Safety Storage Project New 100 8 0 Form and Instruction 0917-00360105-a Firearm Safety Survey
Form 0917-0036-105-b Firearm Survey Form
Fort Washakie Medical Home Patient Feedback Unchanged 200 33 0 Form and Instruction 0917-0036 Fort Washakie Medical Home Patient Feedback
Four Corners Regional Health Center Public Health Nursing Patient Satisfaction Survey New 50 4 0 Form and Instruction 0917-0036-149 Four Corners Regional HC PHN Survey
General Survey for IHS Division of Diabetes Online Catalog New 200 13 0 Form and Instruction 0917-0036-125 General Survey for IHS Division of Diabetes Online Catalog
Health Promotion Disease Prevention Activities Registration Unchanged 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 Unchanged 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 Division of Diabetes Treatment and Prevention (DDTP) Online Catalog Survey for those that Order Materials New 200 17 0 Form and Instruction 0917-0036-131 DDTP Online Catalog Survey for those that Order Materials
IHS Division of Grants Management Needs Assessment Survey New 954 80 0 Form and Instruction 0917-0036-137 DGM Needs Assessment Survey - Recipients
Form and Instruction 0917-0036-0137 DGM Needs Assessment Survey - Staff
IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey Unchanged 325 108 0 Form and Instruction 9017-0036 IHS CHR Survey
IHS Patient Experience Survey Unchanged 40 3 0 Form and Instruction 0917-0036 IHS Patient Experience Survey
IHS Patient Experience of Care Survey New 10000 333 0 Other-survey
IHS Patient Experience of Care Survey for Telehealth New 500 42 0 Form and Instruction 0917-0036-223 IHS Patient Experience of Care Survey for Telehealth
IHS Pharmacy Automation 2015 Survey Unchanged 200 33 0 Form and Instruction 0917-0036 IHS Pharmacy Automation 2015 Survey
IHS Provider Survey for Telehealth New 400 33 0 Form and Instruction 0917-0036-122 Telehelath Survey - RingMD
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 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 Culture of Safety Surveys New 2500 625 0 Form and Instruction 0917-0036 Hospital Survey
Form and Instruction 0917-0036 Medical Office Survey
Indian Health Service National Health Coaching Pilot Project Registration Unchanged 100 8 0 Form and Instruction 0917-0036 HCW Application
Information Technology (IT) Service Management - Service Now Customer Satisfaction Survey New 3000 500 0 Form and Instruction 0917-0036-104 Service Now Surveys
Information Technology (IT) Service Management - Service Now Customer Satisfaction Survey New 3000 500 0 Form and Instruction 0917-0036-102 Survey Now
Innovative Session Partnership Conference Unchanged 90 2 0 Other-Discussion Questions
JUST MOVE IT REGISTRATION FORM New 2300 192 0 Form and Instruction 0917-0036-129 JUST MOVE IT REGISTRATION FORM
JUST MOVE IT REGISTRATION FORM New 4750 396 0 Form and Instruction 0917-0036-135 JMI
Just Move It Registration New 1500 125 0 Form and Instruction 0917-0036-108 JMI Registration Form
KSU Turkey Trot Registration New 500 42 0 Form and Instruction 0917-0036-141 Turkey Trot
Laboratory Needs Assessment New 60 15 0 Form and Instruction 0917-0036 Lab Needs Assessment
Laboratory Training Evaluation Unchanged 35 6 0 Form and Instruction 0917-0036 Lab Survey
MASU Health Fair Survey New 400 47 0 Form and Instruction 0917-0036-110 MASU survey
Medication Lock Box Survey New 250 21 0 Form and Instruction 0917-0036-107 OCA Eval
Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey Unchanged 125 19 0 Form and Instruction 87 MAT Provider Survey
Form and Instruction 87-1 PrEP Questionnaire
Naloxone Safety Net Program New 20 2 0 Form and Instruction 0917-0036 Naloxone Safety Net Program Worksheet
National Center for Injury Prevention and Control (NCIPC) Fellows & Interns' Evaluation New 200 50 0 Form and Instruction 0917-0036-102 CCRT Impact Survey
Northern Cheyenne Service Unit Transportation Department New 75 6 0 Form and Instruction 0917-0036 Northern Cheyenne Service Unit Transportation Department
OCA Locking Medication Bottle Evaluation Survey New 500 17 0 Form and Instruction 0917-0036-124 OCA Locking Medication Bottle Evaluation Survey
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 RPMS Training Needs Assessment New 500 125 0 Form and Instruction 0917-0036-136 RPMS needs assessment
OIT RPMS Training Needs Assessment 2022 New 637 159 0 Form and Instruction 0917-0036-110 Needs Assessment Survey
OIT RPMS Training Needs Assessment Survey Unchanged 727 182 0 Form and Instruction 0917-0036 FY21 OIT RPMS Training Needs Assessment Survey
OIT RPMS Training Post Class Survey Unchanged 2000 167 0 Form and Instruction 0916-0036 ELearning Survey
Form and Instruction 0917-0036 Classroom Survey
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)
Participant Registration Form for WINGS OF AMERICA RUNNING & FITNESS CAMP New 150 13 0 Form and Instruction 0917-0036-127 Participant Registration Form for WINGS OF AMERICA RUNNING & FITNESS CAMP
Partnership Survey New 60 5 0 Form and Instruction 0917-0036-126 Partnership 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 Unchanged 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 New 10000 333 0 Form and Instruction 0917-0036-128 Patient Experience of Care 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 Unchanged 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, 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, at Cheyenne River Health Center (CRHC) Unchanged 540 45 0 Form and Instruction 0917-0036 Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)
Patient Satisfaction Survey: Response to Opioid Use Disorder (OUD) Treatment New 50 4 0 Form and Instruction 0917-0036-121 OUD Survey
Patient Satisfaction survey for Behavioral Health Department New 960 80 0 Form and Instruction 0917-0036-138 Behavioral Health Patient Satisfaction Survey
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)
Pelvic Health Physical Therapy Surveys New 100 8 0 Form and Instruction 0917-0036-120 PP Low Back Pelvic Girdle Pain Survey
Form and Instruction 0917-0036-120a PP Physical Therapy Survey
Form and Instruction 0917-0036-120b UI Class Survey
Physician/Dentist Customer Service Questionnaire Unchanged 500 42 0 Form and Instruction 0917-0036 Physician/Dentist Customer Service Questionnaire
Public Health Compliance Initiative (PHCI) New 50 10 0 Form and Instruction 0917-0036-110 PHCI
Public Health Nursing Data Mart Survey Unchanged 123 21 0 Form and Instruction 0917-0036 Public Health Nursing (PHN) Data Mart Survey Questions
Registration for the Indian Health Service (IHS) Patient Registration Training New 200 17 0 Form and Instruction 0917-0036-109 Pat Registration
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
Stakeholders Satisfaction Questionnaire New 200 3 0 Form and Instruction 0917-0036-106 Satisfaction Survey
Suicide Prevention Conference Survey New 150 13 0 Form and Instruction 0917-0036--164 Suicide Prevention Survey
T-TAQ (TeamSTEPPS Teamwork Attitudes Questionnaire) New 45 4 0 Form and Instruction 0917-0036 TeamSTEPPS
Tele-Behavioral Health Center of Excellence (TBHCE) Survey Unchanged 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
The Community Tobacco Prevention Assessment and Community COVID-19 Prevention Assessment New 1000 83 0 Form and Instruction 0917-0036 Community Commercial Tobacco Use Survey
Form and Instruction 0917-0036 Community COVID19 Prevention Assessment
Tribal Epidemiology Centers (TECs) Survey Collection New 144 912 0 Form and Instruction 0917-0036-160 TEC Survey Questionnaire
Form and Instruction 0917-0036-160 IHS TEC Key Informant Interviews
Form and Instruction 0917-0036-160 IHS TEC Focus Group
Tsaile Health Center DM Patient Survey for 2024 New 150 13 0 Form and Instruction 0917-0036 Tsaile Health Center DM Patient 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
WINGS OF AMERICA RUNNING & FITNESS CAMP New 300 30 0 Form and Instruction 0917-0036-109 Wings Registration Form
WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys Unchanged 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 Unchanged 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: 109532 10410 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
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