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Federal forms, ICRs, and supporting documents

Information Collection Request

IHS COMMUNITY HEALTH REPRESENTATIVE ACTIVITY REPORTING SAMPLE

ICR 199312-0917-002 · 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
110459 IHS COMMUNITY HEALTH REPRESENTATIVE ACTIVITY REPORTING SAMPLE Migrated
ICR Details
0917-0010 199312-0917-002
Historical Active 199203-0917-001
HHS/IHS
IHS COMMUNITY HEALTH REPRESENTATIVE ACTIVITY REPORTING SAMPLE
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 02/08/1994
Retrieve Notice of Action (NOA) 12/17/1993
  Inventory as of this Action Requested Previously Approved
02/28/1997 02/28/1997
6,200 0 0
9,072 0 0
0 0 0
THE IHS CHR OBTAINS DATA ON: SERVICE CATEGORY, HEALTH AREA, SETTING, PATIENT'S AGE AND SEX, REFERRAL FROM, REFERRAL TO, AND MINUTES PROVIDI SERVICE OR IN TRAVEL.
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 6,200 0 0 6,200 0 0
Annual Time Burden (Hours) 9,072 0 0 9,072 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
12/17/1993