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Federal forms, ICRs, and supporting documents

Information Collection Request

IHS COMMUNITY HEALTH REPRESENTATIVE ACTIVITY REPORTING SAMPLE

ICR 198912-0917-001 · OMB 0917-0010 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
110457 IHS COMMUNITY HEALTH REPRESENTATIVE ACTIVITY REPORTING SAMPLE Migrated
ICR Details
0917-0010 198912-0917-001
Historical Active 198901-0917-001
HHS/IHS
IHS COMMUNITY HEALTH REPRESENTATIVE ACTIVITY REPORTING SAMPLE
Extension without change of a currently approved collection   No
Regular
Approved without change 02/12/1990
Retrieve Notice of Action (NOA) 12/18/1989
  Inventory as of this Action Requested Previously Approved
02/28/1992 02/28/1992 03/31/1990
5,644 0 5,644
8,466 0 8,466
0 0 0
THE INFORMATION COLLECTION OBTAINS IHS COMMUNITY HEALTH REPRESENTATIVE PROGRAM DATA ON: SERVICE CATEGORY, HEALTH AREA, SETTING, PATIENT'S AGE AND SEX, REFERRED FROM, REFERRED TO, AND MINUTES PROVIDING SERVICE OR IN TRAVEL. THIS INFORMATION IS COLLECTED DURING ONE WEEK PER MONTH REPORTED TO IHS QUARTERLY AND USED BY CHR PROJECT MANAGERS AND IHS ARE OFFICE AND HQ STAFF FOR PROGRAMMING, PLANNING, ALLOCATION OF
None
None
No
1
IC Title Form No. Form Name
IHS COMMUNITY HEALTH REPRESENTATIVE ACTIVITY REPORTING SAMPLE
  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 5,644 5,644 0 0 0 0
Annual Time Burden (Hours) 8,466 8,466 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  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.
12/18/1989