OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

ICR 201301-0917-001 · OMB 0917-0036 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form OMB No. 0917-0036 OMB No. 0917-0036, We Care Survey, Blackfeet Community Hospital Form and Instruction New Repair queued
Form OMB No. 0917-0036 OMB No. 0917-0036 – Clinical Decision Support Usability Assessment Form and Instruction New Available
Form 0917-0036 Patient Satisfaction Survey, Crow Service Unit Form and Instruction New Available
Form 0917-0036 OMB No. 0917-0036, Sugar Shockers Health Campaign Survey, Catawba Service Unit Form and Instruction New Repair queued
Form 0917-0036 User satisfaction data collection for the IHS OIT NDW Form and Instruction New Available
Form 0917-0036 We Care Survey, Northern Cheyenne Form and Instruction New Repair queued
Form 0917-0036 OMB No. 0917-0036 Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey Form and Instruction New Repair queued
Form 0917-0036 Catawba Service Unit Patient Satisfaction Survey Form and Instruction New Repair queued
Form 0917-0036 OMB No. 0917-0036, Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment Form and Instruction New Repair queued
Form OMB 0917-0036 We Care Survey, Fort Peck SU IHS Form and Instruction New Repair queued
Form 0917-0036 THC Dental Patient Satisfaction Survey Form and Instruction New Repair queued
Form 0917-0036 Patient Satisfaction Survey, Tohatchi Form and Instruction New Repair queued
Form 0917-0036-38 Gallup Service Unit Patient Satisfaction Survey Form and Instruction New Repair queued
Form OMB 0917-0036-0031 EHR Pharmacy Residence Informaticists Survey Form and Instruction New Repair queued
Form OMB No. 0917-0036- Providers - e-RX Deployment Form and Instruction New Available
Form 0917-0036-36 Patient Satisfaction Survey, Alburquerque Service Unit Form and Instruction New Repair queued
Form 0917-0036-34 Dental Patient Satisfaction Survey Form and Instruction New Available
Form 0917-0036-33 Patient Flow Time Study Form and Instruction New Available
Form 0917-0036-32 Patient Satisfaction Survey, at CRHC Form and Instruction New Repair queued
Form OMB No. 0917-0036- RPMS eLearning Hands-on Customer Satisfaction Survey Form and Instruction New Repair queued
Form 0917-0036-28 RPMS Computer Based Post Class Survey Form and Instruction New Available
Form 0917-0036-27 IHS Website ICD-10 Stakeholder Readiness Survey - ICD-10 Project Needs Assessment Form and Instruction New Repair queued
Form OMB No. 0917-0036- Indian Health Service (IHS) Patient Experience Survey Form and Instruction New Repair queued
Form 0917-0036-23 RPMS Annual Training Needs Assessment Form and Instruction New Repair queued
Form OMB No. 0917-0036- VPN User Survey Form and Instruction New Repair queued
Form 0917-0036-21 Portland Area Division of Environmental Health Services: Customer Service Assessment Form and Instruction New Available
Form 0917-0036-18 IHS Clinical Rounds Qualitative Feedback Form and Instruction New Available
Form 0917-0036-17 Community Health Representatives (CHR) National Education Training (NET) Form and Instruction New Repair queued
Form 0917-0036-20 IHS OEHE Customer Satisfaction Survey Form and Instruction New Repair queued
Form OMB No. 0917-0036- IHS Pharmacy Automation Survey 2013 Form and Instruction New Available
Form OMB No. 0917-0036- Community Health Representatives (CHR) Online Diabetes Training Evaluation Form and Instruction New Repair queued
Justification for Burden Increase.docx Justification for No Material/Nonsubstantive Change Uploaded 2013-01-18 Available
IC Document Collections
IC IDCollectionTypeStatusForm
215747 OMB No. 0917-0036, We Care Survey, Blackfeet Community Hospital Form and Instruction New
215692 OMB No. 0917-0036 – Clinical Decision Support Usability Assessment Form and Instruction New
215641 Patient Satisfaction Survey, Crow Service Unit Form and Instruction New
215493 OMB No. 0917-0036, Sugar Shockers Health Campaign Survey, Catawba Service Unit Form and Instruction New
214984 User satisfaction data collection for the IHS OIT NDW Form and Instruction New
214196 We Care Survey, Northern Cheyenne Form and Instruction New
214182 OMB No. 0917-0036 Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey Form and Instruction New
211841 Catawba Service Unit Patient Satisfaction Survey Form and Instruction New
211814 OMB No. 0917-0036, Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment Form and Instruction New
211657 We Care Survey, Fort Peck SU IHS Form and Instruction New
211548 THC Dental Patient Satisfaction Survey Form and Instruction New
211447 Patient Satisfaction Survey, Tohatchi Form and Instruction New
211031 Gallup Service Unit Patient Satisfaction Survey Form and Instruction New
210646 EHR Pharmacy Residence Informaticists Survey Form and Instruction New
210541 Providers - e-RX Deployment Form and Instruction New
210529 Patient Satisfaction Survey, Alburquerque Service Unit Form and Instruction New
210381 Dental Patient Satisfaction Survey Form and Instruction New
210199 Patient Flow Time Study Form and Instruction New
210159 Patient Satisfaction Survey, at CRHC Form and Instruction New
209925 RPMS eLearning Hands-on Customer Satisfaction Survey Form and Instruction New
209717 RPMS Computer Based Post Class Survey Form and Instruction New
209486 IHS Website ICD-10 Stakeholder Readiness Survey - ICD-10 Project Needs Assessment Form and Instruction New
208302 Indian Health Service (IHS) Patient Experience Survey Form and Instruction New
207595 RPMS Annual Training Needs Assessment Form and Instruction New
207443 VPN User Survey Form and Instruction New
206923 Portland Area Division of Environmental Health Services: Customer Service Assessment Form and Instruction New
206413 IHS Clinical Rounds Qualitative Feedback Form and Instruction New
206300 Community Health Representatives (CHR) National Education Training (NET) Form and Instruction New
205725 IHS OEHE Customer Satisfaction Survey Form and Instruction New
205657 IHS Pharmacy Automation Survey 2013 Form and Instruction New
205629 Community Health Representatives (CHR) Online Diabetes Training Evaluation Form and Instruction New
ICR Details
0917-0036 201301-0917-001
Historical Active 201205-0917-002
HHS/IHS
Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 01/31/2013
Retrieve Notice of Action (NOA) 01/18/2013
OMB approves this collection for a period of three years. To request approval of information collections under this generic approval, the agency must do the following: 1) Unless an agency is using multiple modes of collection (e.g., paper forms and electronic submissions), provide a Generic Clearance Submission Template for each Instrument; 2) If the agency is using multiple modes of collection (e.g., paper forms and electronic submissions), the same Generic Clearance Submission Template may be used for both instruments; 3) each Generic Clearance Submission Template must be uploaded as a Supplementary document using a naming convention that allows the public to identify the associated instrument; 4) submit no more than five Generic Submission Templates with each request.
  Inventory as of this Action Requested Previously Approved
05/31/2015 05/31/2015 05/31/2015
105,000 0 3,030
40,000 0 1,030
0 0 0
This fast track generic collection of infomration is neccesssary to enable IHS to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improving service delivery. The information collected from our customers and stakeholders will help ensure that users have an effective, efficeint, and satisfying experience with the Agency's programs.
US Code: 44 USC 3501 Name of Law: Paperwork Reduction Act
   EO: EO 12682 Name/Subject of EO: "Setting Customer Service Standards"
  
None
Not associated with rulemaking
No
31
IC Title Form No. Form Name
IHS Pharmacy Automation Survey 2013 OMB No. 0917-0036-19 OMB No. 0917-0036-19, IHS Pharmacy Automation Survey
OMB No. 0917-0036, We Care Survey, Blackfeet Community Hospital OMB No. 0917-0036 We Care Survey, Blackfeet Community Hospital
OMB No. 0917-0036 Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey 0917-0036, 0917-0036, 0917-0036 Coordinated Care Survey ,   Patient Registration Survey ,   Patient Wellness Survey
We Care Survey, Fort Peck SU IHS OMB 0917-0036 We Care Survey, Fort Peck SU IHS
RPMS eLearning Hands-on Customer Satisfaction Survey OMB No. 0917-0036-30 OMB No. 0917-0036-30, RPMS eLearning Hands-on Customer Satisfaction Survey
Indian Health Service (IHS) Patient Experience Survey OMB No. 0917-0036-24 OMB No. 0917-0036-24, IPC Patient Experience Survey
Catawba Service Unit Patient Satisfaction Survey 0917-0036 Catawaba Service Unit Patient Satisfaction Survey
IHS Website ICD-10 Stakeholder Readiness Survey - ICD-10 Project Needs Assessment 0917-0036-27 OMB No. 0917-0036-27, IHS Website ICD-10 Stakeholder Readiness Survey - ICD-10 Project Needs Assessment
RPMS Annual Training Needs Assessment 0917-0036-23 OMB No. 0917-0036-23, IHS RPMS Annual Training Needs Assessment
We Care Survey, Northern Cheyenne 0917-0036 We Care Patient Satisfaction Survey for Nothern Cheyenne
RPMS Computer Based Post Class Survey 0917-0036-28 0917-0036-28, Computer Training Post Class Survey
Providers - e-RX Deployment OMB No. 0917-0036-35 OMB No. 0917-0036-35, Providers - eRX Deployment
OMB No. 0917-0036, Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment 0917-0036 OMB No. 0917-0036, Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment
Patient Flow Time Study 0917-0036-33 Patient Flow Time Study
IHS OEHE Customer Satisfaction Survey 0917-0036-20, 0917-0036-20, 0917-0036-20, 0917-0036-20 0917-0036-20, Post Construction O & M Survey ,   0917-0036-20, Annual Operator O & M Survey ,   0917-0036-20, Tribal Homeowner Survey ,   0917-0036-20, Tribal Partner Survey
Patient Satisfaction Survey, at CRHC 0917-0036-32 Patient Satisfaction Survey, at Cheyenne River Health Center
Community Health Representatives (CHR) Online Diabetes Training Evaluation OMB No. 0917-0036-16 OMB No. 0917-0036-16, IHS CHR Online Diabetes Training Evaluation Form
VPN User Survey OMB No. 0917-0036-22 OMB Form No. 0917-0036-22, IHS VPN User Survey
EHR Pharmacy Residence Informaticists Survey OMB 0917-0036-0031 OMB 0917-0036-0031, EHR Pharmacy Resident Informaticist Survey
Gallup Service Unit Patient Satisfaction Survey 0917-0036-38 OMB No. 0917-0036-38, Gallup Service Unit Patient Satisfaction Survey
OMB No. 0917-0036 – Clinical Decision Support Usability Assessment OMB No. 0917-0036 Clinical Decision Support Usabibility Assessment - Local Clinical Reminders
Community Health Representatives (CHR) National Education Training (NET) 0917-0036-17 OMB No. 0917-0036-17, IHS CHR NET Plenary Eval Form
THC Dental Patient Satisfaction Survey 0917-0036 THC Dental Patient Satisfaction Survey
Patient Satisfaction Survey, Crow Service Unit 0917-0036 Patient Satisfaction Survey, Crow Service Unit
Patient Satisfaction Survey, Alburquerque Service Unit 0917-0036-36 OMB No. 0917-0036-36, Patient Satisfaction Survey, Albuquerque Service Unit
User satisfaction data collection for the IHS OIT NDW 0917-0036 Indian Health Service, Office of Information Technology, National Patient Reporting System National Data Warehouse Data Collection Survey
Dental Patient Satisfaction Survey 0917-0036-34 0917-0036-34, Dental Patient Satisfaction Survey
Patient Satisfaction Survey, Tohatchi 0917-0036 OMB No. 0917-0036-39, Patient Satisfaction Survey, Tohatchi
Portland Area Division of Environmental Health Services: Customer Service Assessment 0917-0036-21 OMB No 0917-0036-21, Portland Area Division of Environmental Health Services: Customer Services Assessment
IHS Clinical Rounds Qualitative Feedback 0917-0036-18 0917-0036-18, IHS Clinical Rounds Qualitative Feedback Form
OMB No. 0917-0036, Sugar Shockers Health Campaign Survey, Catawba Service Unit 0917-0036 Sugar Shockers Health Campaign Survey, at Catawaba, SU
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 105,000 3,030 0 0 101,970 0
Annual Time Burden (Hours) 40,000 1,030 0 0 38,970 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$15,000
Yes Part B of Supporting Statement
No
No
No
No
Uncollected
Tamara Clay 301 443-4750 [email protected]
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
01/18/2013