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
2024 Health IT Modernization Tribal Consultation/Urban Confer Satisfaction Survey New 300 65 0 Form and Instruction 0917-0036
Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit (CSU) Unchanged 1200 120 0 Form and Instruction 0917-0036
Afterschool Student Wellness Program – Parent Feedback New 80 7 0 Form and Instruction 0917-0036-125
Anticoagulation Clinic Patient Satisfaction Survey Unchanged 15 2 0 Form and Instruction 0917-0036
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
CSU Employee Wellness Survey New 500 125 0 Form and Instruction 0917-0036-140
Catawba Service Unit Patient Satisfaction Survey Unchanged 360 30 0 Form and Instruction 0917-0036
Chinle Event Survey New 250 42 0 Form and Instruction 0917-0036-134
Chinle Mobile Health Unit (MHU) Customer Satisfaction and Needs Survey New 500 25 0 Form and Instruction 0917-0036-163
Chinle Service Unit (CSU) Employee Satisfaction Survey. Unchanged 2400 240 0 Form and Instruction 0917-0036
Chinle Wellness Center 7th Annual Half Marathon & 10K New 400 40 0 Form and Instruction 0917-0036-109
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 Unchanged 41 1 0 Form 0917-0036-86
Dental Professionals & Human Papillomavirus (HPV) Prevention Survey Unchanged 500 92 0 Form and Instruction 9017-0036
Developing Resilience Survey New 29 2 0 Form and Instruction 0917-0036-103
Diabetes Care Survey Unchanged 40 3 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
Firearm Safety Storage Project New 100 8 0 Form and Instruction 0917-00360105-a
Form 0917-0036-105-b
Fort Washakie Medical Home Patient Feedback Unchanged 200 33 0 Form and Instruction 0917-0036
Four Corners Regional Health Center Public Health Nursing Patient Satisfaction Survey New 50 4 0 Form and Instruction 0917-0036-149
General Survey for IHS Division of Diabetes Online Catalog New 200 13 0 Form and Instruction 0917-0036-125
Health Promotion Disease Prevention Activities Registration Unchanged 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 Unchanged 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 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
IHS Division of Grants Management Needs Assessment Survey New 954 80 0 Form and Instruction 0917-0036-137
Form and Instruction 0917-0036-0137
IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey Unchanged 325 108 0 Form and Instruction 9017-0036
IHS Patient Experience Survey Unchanged 40 3 0 Form and Instruction 0917-0036
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 Pharmacy Automation 2015 Survey Unchanged 200 33 0 Form and Instruction 0917-0036
IHS Provider Survey for Telehealth New 400 33 0 Form and Instruction 0917-0036-122
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 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 Culture of Safety Surveys New 2500 625 0 Form and Instruction 0917-0036
Form and Instruction 0917-0036
Indian Health Service National Health Coaching Pilot Project Registration Unchanged 100 8 0 Form and Instruction 0917-0036
Information Technology (IT) Service Management - Service Now Customer Satisfaction Survey New 3000 500 0 Form and Instruction 0917-0036-104
Information Technology (IT) Service Management - Service Now Customer Satisfaction Survey New 3000 500 0 Form and Instruction 0917-0036-102
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 New 4750 396 0 Form and Instruction 0917-0036-135
Just Move It Registration New 1500 125 0 Form and Instruction 0917-0036-108
KSU Turkey Trot Registration New 500 42 0 Form and Instruction 0917-0036-141
Laboratory Needs Assessment New 60 15 0 Form and Instruction 0917-0036
Laboratory Training Evaluation Unchanged 35 6 0 Form and Instruction 0917-0036
MASU Health Fair Survey New 400 47 0 Form and Instruction 0917-0036-110
Medication Lock Box Survey New 250 21 0 Form and Instruction 0917-0036-107
Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey Unchanged 125 19 0 Form and Instruction 87
Form and Instruction 87-1
Naloxone Safety Net Program New 20 2 0 Form and Instruction 0917-0036
National Center for Injury Prevention and Control (NCIPC) Fellows & Interns' Evaluation New 200 50 0 Form and Instruction 0917-0036-102
Northern Cheyenne Service Unit Transportation Department New 75 6 0 Form and Instruction 0917-0036
OCA Locking Medication Bottle Evaluation Survey New 500 17 0 Form and Instruction 0917-0036-124
OIT Customer Satisfaction Survey – Problem Ticket Unchanged 500 42 0 Form and Instruction 0917-0036
Form and Instruction 0917-0036
OIT RPMS Training Needs Assessment New 500 125 0 Form and Instruction 0917-0036-136
OIT RPMS Training Needs Assessment 2022 New 637 159 0 Form and Instruction 0917-0036-110
OIT RPMS Training Needs Assessment Survey Unchanged 727 182 0 Form and Instruction 0917-0036
OIT RPMS Training Post Class Survey Unchanged 2000 167 0 Form and Instruction 0916-0036
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
Participant Registration Form for WINGS OF AMERICA RUNNING & FITNESS CAMP New 150 13 0 Form and Instruction 0917-0036-127
Partnership Survey New 60 5 0 Form and Instruction 0917-0036-126
Patient Assessment –Clinton Service Unit - IMPRESS Unchanged 500 42 0 Form and Instruction 0917-0036
Patient Experience Surveys - White Earth Service Unit Unchanged 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 New 10000 333 0 Form and Instruction 0917-0036-128
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 Unchanged 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, Optometry Dept. White Earth Service Unit Indian Health Service Unchanged 200 10 0 Form and Instruction 0917-0036-12
Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC) Unchanged 540 45 0 Form and Instruction 0917-0036
Patient Satisfaction Survey: Response to Opioid Use Disorder (OUD) Treatment New 50 4 0 Form and Instruction 0917-0036-121
Patient Satisfaction survey for Behavioral Health Department New 960 80 0 Form and Instruction 0917-0036-138
Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit (CSU) Unchanged 420 42 0 Form and Instruction 0917-0036
Pelvic Health Physical Therapy Surveys New 100 8 0 Form and Instruction 0917-0036-120
Form and Instruction 0917-0036-120a
Form and Instruction 0917-0036-120b
Physician/Dentist Customer Service Questionnaire Unchanged 500 42 0 Form and Instruction 0917-0036
Public Health Compliance Initiative (PHCI) New 50 10 0 Form and Instruction 0917-0036-110
Public Health Nursing Data Mart Survey Unchanged 123 21 0 Form and Instruction 0917-0036
Registration for the Indian Health Service (IHS) Patient Registration Training New 200 17 0 Form and Instruction 0917-0036-109
Special Care Unit (SCU) Patient Experience Survey, Chinle Service Unit Unchanged 360 36 0 Form and Instruction 0917-0036
Stakeholders Satisfaction Questionnaire New 200 3 0 Form and Instruction 0917-0036-106
Suicide Prevention Conference Survey New 150 13 0 Form and Instruction 0917-0036--164
T-TAQ (TeamSTEPPS Teamwork Attitudes Questionnaire) New 45 4 0 Form and Instruction 0917-0036
Tele-Behavioral Health Center of Excellence (TBHCE) Survey Unchanged 300 50 0 Form and Instruction 9017-0036
Telebehavioral Health Patient Satisfaction Survey Unchanged 40 3 0 Form 0917-0036
The Community Tobacco Prevention Assessment and Community COVID-19 Prevention Assessment New 1000 83 0 Form and Instruction 0917-0036
Form and Instruction 0917-0036
Tribal Epidemiology Centers (TECs) Survey Collection New 144 912 0 Form and Instruction 0917-0036-160
Form and Instruction 0917-0036-160
Form and Instruction 0917-0036-160
Tsaile Health Center DM Patient Survey for 2024 New 150 13 0 Form and Instruction 0917-0036
User satisfaction data collection for the IHS OIT NDW Unchanged 487 81 0 Form and Instruction 0917-0036
WINGS OF AMERICA RUNNING & FITNESS CAMP New 300 30 0 Form and Instruction 0917-0036-109
WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys Unchanged 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 Unchanged 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: 109532 10410 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
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