Information Collection

IHS Background Investigation of Individuals in Positions Involving Regular Contact with or Control Over Indian Children

IC 6586 under ICR 201811-0917-002 · OMB 0917-0028.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0028 can be found here:

Documents and Forms

Document Name Document Type
Form 0917-0028 IHS Background Investigation of Individuals in Positions Involving Regular Contact with or Control Over Indian Children Form and Instruction
0917-0028 Final Addendum to Declaration of Federal Employment Final_AddendumtoDeclarationorFederalEmploymentOGCPHD final copy 9.20.18.doc www.ihs.gov/jobs/ Form and Instruction
OMB Form No. 3206-0182 0306[1].pdf Declaration for Federal Employment (OPM OF 306; OMB No. 3206-0182) IC Document
2018-20989.pdf 60 Day FRN IC Document
2018-25819.pdf 30 day FRN IC Document
0917-0028_Supporting_Statement_A__2018.doc Supporting Statement IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	IHS Background Investigation of Individuals in Positions Involving Regular Contact with or Control Over Indian Children	Agency IC Tracking Number:	0917-0028

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 136.401-418

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0917-0028	Final Addendum to Declaration of Federal Employment	Final_AddendumtoDeclarationorFederalEmploymentOGCPHD final copy 9.20.18.doc	https://www.ihs.gov/jobs/	Yes	No	Fillable Printable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	600	600
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Declaration for Federal Employment (OPM OF 306; OMB No. 3206-0182)	OMB Form No. 3206-0182 0306[1].pdf	06/11/2012
60 Day FRN	2018-20989.pdf	11/28/2018
30 day FRN	2018-25819.pdf	11/28/2018
Supporting Statement	0917-0028_Supporting_Statement_A__2018.doc	11/28/2018

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