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Indian Health Service Purchased/Referred Care Patient Experience Survey
Instructions: Please select the response that best matches your answer for questions below.
Confidentiality: Your responses to this survey are voluntary and confidential to the extent provided by law. This survey is an attempt to improve Purchased/Referred Care services. IHS is not requesting Protected Health Information or Personally Identifiable Information (PHI/PII), which includes, but is not limited to name, medical conditions, IHS employees or IHS contractors, names). Please do not enter PHI/PII in the text boxes. Please review the IHS Privacy Policy prior to beginning the survey.
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Burden Statement: According to the Paperwork Reduction Act of 1995, an Agency may not conduct, nor sponsor, and no persons are required to respond to a collection of information unless it displays a valid OMB control number. The approved OMB Control Number for this information collection is 0990-0491 (expires 4/30/2027). Without this approval, we could not conduct this survey. Public reporting for this survey is estimated to be approximately 9 minutes per response, including the time to review instructions, search existing data resources, gather and maintain the data needed to review and complete the information collection. All responses to this survey are voluntary. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden or for improving this form to: Indian Health Service, OMS/DRPC, 5600 Fishers Lane, mailstop: 09E70, Rockville, MD 20857, Attention: Information Collections Clearance Officer.