Anticoagulation Clinic Patient Satisfaction Survey

Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: IHS Customer Service Satisfaction and Similar Surveys

Documents and Forms

Document Name Document Type
Form 0917-0036 Anticoagulation Clinic Patient Satisfaction Survey Form and Instruction
0917-0036 Anticoagulation Clinic Patient Satisfaction Survey Anticoagulation Services Patient Satisfaction Survey 8.10.21.docx Form and Instruction
0917-0036 Anticoagulation Clinic Patient Satisfaction Survey Anticoagulation Services Patient Satisfaction Survey 8.10.21.docx Form and Instruction
Generic Clearance Submission - WWKMHCC Anticoagulation Clinic Patient Satisfaction Survey 7-21.docx Supporting Statement IC Document
Generic Clearance Submission - WWKMHCC Anticoagulation Clinic Patient Satisfaction Survey 7-21.docx Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	Anticoagulation Clinic Patient Satisfaction Survey	Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0917-0036	Anticoagulation Clinic Patient Satisfaction Survey	Anticoagulation Services Patient Satisfaction Survey 8.10.21.docx		No		Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	2	2
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	Generic Clearance Submission - WWKMHCC Anticoagulation Clinic Patient Satisfaction Survey 7-21.docx	08/11/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.