OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

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

ICR 202201-0917-001 · OMB 0917-0036 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form 0917-0036 Indian Health Service National Health Coaching Pilot Project Registration Form and Instruction Unchanged Repair queued
Form 0917-0036 Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey Form and Instruction Unchanged Repair queued
Form 9017-0036 Patient Satisfaction Survey - Crownpoint Service Unit Form and Instruction Unchanged Repair queued
Form 0916-0036 OIT RPMS Training Post Class Survey Form and Instruction Unchanged Repair queued
Form 0917-0036 Laboratory Training Evaluation Form and Instruction Unchanged Repair queued
Form 0917-0036 Anticoagulation Clinic Patient Satisfaction Survey Form and Instruction Unchanged Repair queued
Form 9017 Health Promotion Disease Prevention Activities Registration Form and Instruction Unchanged Repair queued
Form 1 WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys Form and Instruction Unchanged Repair queued
Form 0917-0036 OIT RPMS Training Needs Assessment Survey Form and Instruction Unchanged Repair queued
Form 0917-0036 Patient Experience Surveys - White Earth Service Unit Form and Instruction Unchanged Repair queued
Form 0917-0036 Diabetes Care Survey Form and Instruction Unchanged Repair queued
Form 0917-0036 IHS Chinle Service Unit Customer Experience Survey Form and Instruction Unchanged Repair queued
Form 9017-0036 Dental Professionals & Human Papillomavirus (HPV) Prevention Survey Form and Instruction Unchanged Repair queued
Form 9017-0036 Tele-Behavioral Health Center of Excellence (TBHCE) Survey Form and Instruction Unchanged Repair queued
Form 87 Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey Form and Instruction Unchanged Repair queued
Form 0917-0036-86 Confer Satisfaction Survey Form Unchanged Repair queued
Form 9017-0036 IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey Form and Instruction Unchanged Repair queued
Form 0917-0036 Evaluation Survey of IHS Mandatory Pain and Opioid Training and Prescriber Habits Form and Instruction Unchanged Repair queued
Form 0917-0036 IHS White Earth Hand Washing Survey Form and Instruction Unchanged Repair queued
Form 0917-0036 Fort Washakie Medical Home Patient Feedback Form and Instruction Unchanged Repair queued
Form 0917-0036-12 Patient Satisfaction Survey, Optometry Dept. White Earth Service Unit Indian Health Service Form and Instruction Unchanged Repair queued
Form 0917-0036-23 IHS Training Needs Survey Form and Instruction Unchanged Repair queued
Form 0917-0036 IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition Form Unchanged Missing upstream
Form 0917-0036 WebTMA Survey Form and Instruction Unchanged Repair queued
Form 0917-0036 Telebehavioral Health Patient Satisfaction Survey Form Unchanged Repair queued
Form 0917-0036 Public Health Nursing Data Mart Survey Form and Instruction Unchanged Repair queued
Form 0917-0036 Patient Experience of Care Survey Pilot Project Form and Instruction Unchanged Repair queued
Form IHS Web Services C IHS Web Services Customer Satisfaction Survey Form Unchanged Repair queued
Form 0917-0036 OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health. Form and Instruction Unchanged Repair queued
Form 0917-0036 Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit (CSU) Form and Instruction Unchanged Repair queued
Form 0917-0036 Obstetric Care Unit (OCU) Patient Experience Survey, Chinle Service Unit Form and Instruction Unchanged Repair queued
Form 0917-0036 Special Care Unit (SCU) Patient Experience Survey, Chinle Service Unit Form and Instruction Unchanged Repair queued
Form 0917-0036 Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit (CSU) Form and Instruction Unchanged Repair queued
Form 0917-0036 Chinle Service Unit (CSU) Employee Satisfaction Survey. Form and Instruction Unchanged Missing upstream
Form 0917-0036 We Care Survey, Fort Peck Service Unit Indian Health Service Form and Instruction Unchanged Repair queued
Form 0917-0036 Clinical Decision Support Usability Assessment Form and Instruction Unchanged Repair queued
Form 0917-0036 User satisfaction data collection for the IHS OIT NDW Form and Instruction Unchanged Repair queued
Form 0917-0036 We Care Survey, Northern Cheyenne Form and Instruction Unchanged Repair queued
Form 0917-0036 We Care Survey, Blackfeet Community Hospital. Form and Instruction Unchanged Repair queued
Form 0917-0036 Catawba Service Unit Patient Satisfaction Survey Form and Instruction Unchanged Repair queued
Form 0917-0036 IHS RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment Form and Instruction Unchanged Repair queued
Form 0917-0036 We Care Survey, Fort Peck Service Unit Indian Health Service Form and Instruction Unchanged Repair queued
Form 0917-0036 Patient Satisfaction Survey, Alburquerque Service Unit Form and Instruction Unchanged Repair queued
Form 0917-0036 White Earth Dental Clinic Patient Satisfaction Survey Form and Instruction Unchanged Repair queued
Form 0917-0036 Patient Flow Time Study Form and Instruction Unchanged Repair queued
Form 0917-0036 Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC) Form and Instruction Unchanged Repair queued
Form 0917-0036 eLearning Hands-on Customer Satisfaction Survey Form and Instruction Unchanged Repair queued
Form 0917-0036 Computer Based Post Class Survey Form and Instruction Unchanged Repair queued
Form 0917-0036 IHS Patient Experience Survey Form and Instruction Unchanged Repair queued
Form 0917-0036 IHS Pharmacy Automation 2015 Survey Form and Instruction Unchanged Repair queued
Form 0917-0036 Indian Health Service (IHS) Clinical Rounds Qualitative Feedback Form and Instruction Unchanged Repair queued
Form 0917-0036 IHS CHR NET Plenary Evaluation Form Form and Instruction Unchanged Repair queued
Form 0917-0036 Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation Form and Instruction Unchanged Repair queued
Form 0917-0036 OIT Customer Satisfaction Survey – Problem Ticket Form and Instruction Unchanged Repair queued
Form 0917-0036 Physician/Dentist Customer Service Questionnaire Form and Instruction Unchanged Repair queued
Form 0917-0036 Patient Assessment –Clinton Service Unit - IMPRESS Form and Instruction Unchanged Repair queued
Form 0917-0036 Employee Assessment- Clinton Service Unit - IMPRESS Form and Instruction Unchanged Repair queued
Form 0917-0036 Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey Form and Instruction Unchanged Repair queued
Form 0917-0036 Indian Health Service (IHS) FY_ eLearning Post Class Survey Form and Instruction Unchanged Repair queued
Form 0917-0036 Indian Health Service (IHS) FY_ Classroom Post Class Survey Form and Instruction Unchanged Repair queued
Form 0917-0036 Indian Health Service (IHS Website Feedback Form Form and Instruction Unchanged Repair queued
Supporting Statement A for OMB No. 0917-0036, IHS Fast Track for Generic Clearance 2022 Final 1.13.22.docx Supporting Statement A Uploaded 2022-01-13 Missing upstream
Justification for Burden Increase.docx Justification for No Material/Nonsubstantive Change Uploaded 2013-01-18 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
250384 Indian Health Service National Health Coaching Pilot Project Registration Form and Instruction Unchanged
250081 Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey Form and Instruction Unchanged
250077 Patient Satisfaction Survey - Crownpoint Service Unit Form and Instruction Unchanged
249370 OIT RPMS Training Post Class Survey Form and Instruction Unchanged
249152 Laboratory Training Evaluation Form and Instruction Unchanged
248810 Anticoagulation Clinic Patient Satisfaction Survey Form and Instruction Unchanged
248668 Health Promotion Disease Prevention Activities Registration Form and Instruction Unchanged
247004 WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys Form and Instruction Unchanged
242056 OIT RPMS Training Needs Assessment Survey Form and Instruction Unchanged
237875 Patient Experience Surveys - White Earth Service Unit Form and Instruction Unchanged
237873 Diabetes Care Survey Form and Instruction Unchanged
236418 IHS Chinle Service Unit Customer Experience Survey Form and Instruction Unchanged
236413 Dental Professionals & Human Papillomavirus (HPV) Prevention Survey Form and Instruction Unchanged
236408 Tele-Behavioral Health Center of Excellence (TBHCE) Survey Form and Instruction Unchanged
235443 Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey Form and Instruction Unchanged
235441 Confer Satisfaction Survey Form Unchanged
235243 IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey Form and Instruction Unchanged
230847 Evaluation Survey of IHS Mandatory Pain and Opioid Training and Prescriber Habits Form and Instruction Unchanged
230260 IHS White Earth Hand Washing Survey Form and Instruction Unchanged
229103 Fort Washakie Medical Home Patient Feedback Form and Instruction Unchanged
228427 Patient Satisfaction Survey, Optometry Dept. White Earth Service Unit Indian Health Service Form and Instruction Unchanged
227895 Innovative Session Partnership Conference Other-Discussion Questions Unchanged
227765 IHS Training Needs Survey Form and Instruction Unchanged
226315 IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition Form Unchanged
226049 WebTMA Survey Form and Instruction Unchanged
225049 Telebehavioral Health Patient Satisfaction Survey Form Unchanged
225048 Public Health Nursing Data Mart Survey Form and Instruction Unchanged
224877 Patient Experience of Care Survey Pilot Project Form and Instruction Unchanged
223611 IHS Web Services Customer Satisfaction Survey Form Unchanged
218239 OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health. Form and Instruction Unchanged
217933 Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit (CSU) Form and Instruction Unchanged
217932 Obstetric Care Unit (OCU) Patient Experience Survey, Chinle Service Unit Form and Instruction Unchanged
217748 Special Care Unit (SCU) Patient Experience Survey, Chinle Service Unit Form and Instruction Unchanged
217747 Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit (CSU) Form and Instruction Unchanged
217690 Chinle Service Unit (CSU) Employee Satisfaction Survey. Form and Instruction Unchanged
217673 We Care Survey, Fort Peck Service Unit Indian Health Service Form and Instruction Unchanged
216572 Clinical Decision Support Usability Assessment Form and Instruction Unchanged
216545 User satisfaction data collection for the IHS OIT NDW Form and Instruction Unchanged
216544 We Care Survey, Northern Cheyenne Form and Instruction Unchanged
216538 We Care Survey, Blackfeet Community Hospital. Form and Instruction Unchanged
216532 Catawba Service Unit Patient Satisfaction Survey Form and Instruction Unchanged
216531 IHS RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment Form and Instruction Unchanged
216529 We Care Survey, Fort Peck Service Unit Indian Health Service Form and Instruction Unchanged
216514 Patient Satisfaction Survey, Alburquerque Service Unit Form and Instruction Unchanged
216512 White Earth Dental Clinic Patient Satisfaction Survey Form and Instruction Unchanged
216510 Patient Flow Time Study Form and Instruction Unchanged
216509 Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC) Form and Instruction Unchanged
216500 eLearning Hands-on Customer Satisfaction Survey Form and Instruction Unchanged
216499 Computer Based Post Class Survey Form and Instruction Unchanged
216493 IHS Patient Experience Survey Form and Instruction Unchanged
216464 IHS Pharmacy Automation 2015 Survey Form and Instruction Unchanged
216462 Indian Health Service (IHS) Clinical Rounds Qualitative Feedback Form and Instruction Unchanged
216457 IHS CHR NET Plenary Evaluation Form Form and Instruction Unchanged
216453 Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation Form and Instruction Unchanged
216429 OIT Customer Satisfaction Survey – Problem Ticket Form and Instruction Unchanged
216426 Physician/Dentist Customer Service Questionnaire Form and Instruction Unchanged
216424 Patient Assessment –Clinton Service Unit - IMPRESS Form and Instruction Unchanged
216421 Employee Assessment- Clinton Service Unit - IMPRESS Form and Instruction Unchanged
216417 Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey Form and Instruction Unchanged
216415 Indian Health Service (IHS) FY_ eLearning Post Class Survey Form and Instruction Unchanged
216412 Indian Health Service (IHS) FY_ Classroom Post Class Survey Form and Instruction Unchanged
216396 Indian Health Service (IHS Website Feedback Form Form and Instruction Unchanged
ICR Details
0917-0036 202201-0917-001
Received in OIRA 201804-0917-001
HHS/IHS 1
Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: IHS Customer Service Satisfaction and Similar Surveys
Extension without change of a currently approved collection   No
Regular 01/13/2022
  Requested Previously Approved
36 Months From Approved 01/31/2022
105,000 105,000
17,500 17,500
0 0
This fast track generic collection of information is neccesssary to enable IHS to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improving service delivery. The information collected from our customers and stakeholders will help ensure that users have an effective, efficient, and satisfying experience with the Agency's programs.
EO: EO 12862 Name/Subject of EO: SETTING CUSTOMER SERVICE STANDARDS
   US Code: 44 USC 3501 Name of Law: Paperwork Reduction Act
  
None
Not associated with rulemaking
  86 FR 54462 10/01/2021
87 FR 1764 01/12/2022
No
62
IC Title Form No. Form Name
Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit (CSU) 0917-0036 Adult Care Unit (ACU) Patient Experience Survey, Chinle Service Unit
Anticoagulation Clinic Patient Satisfaction Survey 0917-0036 Anticoagulation Clinic Patient Satisfaction Survey
Catawba Service Unit Patient Satisfaction Survey 0917-0036 Catawba Service Unit Patient Satisfaction Survey
Chinle Service Unit (CSU) Employee Satisfaction Survey. 0917-0036 CSU Employee Survey 2015
Clinical Decision Support Usability Assessment 0917-0036 Clinical Decision Support Usability Assessment
Computer Based Post Class Survey 0917-0036 Computer Based Training (CBT)Post Class Survey
Confer Satisfaction Survey 0917-0036-86 Confer Satisfaction Survey
Dental Professionals & Human Papillomavirus (HPV) Prevention Survey 9017-0036 HPV Survey
Diabetes Care Survey 0917-0036 Diabetes Care Survey
Employee Assessment- Clinton Service Unit - IMPRESS 0917-0036 Employee Assessment- Clinton Service Unit - IMPRESS
Evaluation Survey of IHS Mandatory Pain and Opioid Training and Prescriber Habits 0917-0036 Evaluation Survey
Fort Washakie Medical Home Patient Feedback 0917-0036 Fort Washakie Medical Home Patient Feedback
Health Promotion Disease Prevention Activities Registration 9017 9017
IHS CHR NET Plenary Evaluation Form 0917-0036 IHS CHR NET Plenary Evaluation Form
IHS Chinle Service Unit Customer Experience Survey 0917-0036, 0917-0036 Community Nutrition ,   Gardening Survey
IHS Chinle Service Unit Customer Experience Survey – Clinical and Community Nutrition 0917-0036, 0917-0036 Community Nutrition Gardening Survey ,   RDN Services Survey
IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey 9017-0036 IHS CHR Survey
IHS Patient Experience Survey 0917-0036 IHS Patient Experience Survey
IHS Pharmacy Automation 2015 Survey 0917-0036 IHS Pharmacy Automation 2015 Survey
IHS RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment 0917-0036 Indian Health Service (IHS) RPMS Stakeholder Survey – Resource and Patient Management System Program Operational Analysis Needs Assessment
IHS Training Needs Survey 0917-0036-23 Training Needs Survey
IHS Web Services Customer Satisfaction Survey IHS Web Services Customer Feedback IHS Web Services Customer Feedback
IHS White Earth Hand Washing Survey 0917-0036 Hand Washing Survey
Indian Health Service (IHS Website Feedback Form 0917-0036, 0917-0036 IHS Website Feedback Form ,   IHS Website Customer Satisfaction Survey - First Page
Indian Health Service (IHS) Clinical Rounds Qualitative Feedback 0917-0036 Indian Health Service (IHS) Clinical Rounds Qualitative Feedback
Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation 0917-0036 Indian Health Service (IHS) Community Health Representatives (CHR) Diabetes Online Training Evaluation
Indian Health Service (IHS) FY_ Classroom Post Class Survey 0917-0036 Indian Health Service (IHS) FY_ Classroom Post Class Survey
Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey 0917-0036, 0917-0036 Indian Health Service (IHS) FY_ Satellite Classroom Post Class Survey ,   FY___Satellite Classroom with Areas Post Class Survey
Indian Health Service (IHS) FY_ eLearning Post Class Survey 0917-0036 Indian Health Service (IHS) FY_ eLearning Post Class Survey
Indian Health Service National Health Coaching Pilot Project Registration 0917-0036 HCW Application
Innovative Session Partnership Conference
Laboratory Training Evaluation 0917-0036 Lab Survey
Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey 87, 87-1 MAT Provider Survey ,   PrEP Questionnaire
OIT Customer Satisfaction Survey – Problem Ticket 0917-0036, 0917-0036 OIT Customer Satisfaction Survey – Problem Ticket ,   OIT Customer Satisfaction Survey – Problem Ticket (screen shot)
OIT RPMS Training Needs Assessment Survey 0917-0036 FY21 OIT RPMS Training Needs Assessment Survey
OIT RPMS Training Post Class Survey 0916-0036, 0917-0036 ELearning Survey ,   Classroom Survey
OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health. 0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036 Wellness Center Survey ,   Adolescent School Health ,   Community Nutrition Survey ,   Diabetes Survey ,   Health Promotion Survey ,   Native Medicine Survey ,   Public Health Nursing - for Patient Care Giver - Survey ,   Public Health Nursing - for Patient
Obstetric Care Unit (OCU) Patient Experience Survey, Chinle Service Unit 0917-0036 Obstetrical Care Unit (OCU) Patient Experience Suvey, Chinle Service Unit (CSU)
Patient Assessment –Clinton Service Unit - IMPRESS 0917-0036 Patient Assessment –Clinton Service Unit - IMPRESS
Patient Experience Surveys - White Earth Service Unit 0917-0036, 0917-0036, 0917-0036, 0917-0036, 0917-0036 Dental Survey ,   Lab Dept Survey ,   Optometry Survey ,   Radiology Dept Survey ,   Therapist Survey
Patient Experience of Care Survey Pilot Project 0917-0036 Patient Experience of Care Survey
Patient Flow Time Study 0917-0036 Patient Flow Time Study
Patient Satisfaction Survey - Crownpoint Service Unit 9017-0036 Patient Survey
Patient Satisfaction Survey, Alburquerque Service Unit 0917-0036 Patient Satisfaction Survey, Alburquerque Service Unit
Patient Satisfaction Survey, Optometry Dept. White Earth Service Unit Indian Health Service 0917-0036-12 Patient Satisfaction Survey for the White Earth Optometry Dept.
Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC) 0917-0036 Patient Satisfaction Survey, at Cheyenne River Health Center (CRHC)
Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit (CSU) 0917-0036 Pediatric Care Unit (PCU) Patient Experience Survey, Chinle Service Unit CSU)
Physician/Dentist Customer Service Questionnaire 0917-0036 Physician/Dentist Customer Service Questionnaire
Public Health Nursing Data Mart Survey 0917-0036 Public Health Nursing (PHN) Data Mart Survey Questions
Special Care Unit (SCU) Patient Experience Survey, Chinle Service Unit 0917-0036 Special Care Unit (SCU) Patient Experience Survey
Tele-Behavioral Health Center of Excellence (TBHCE) Survey 9017-0036 LHP Behaviorial Health Training Needs Survey
Telebehavioral Health Patient Satisfaction Survey 0917-0036 Telebehavioral Health Patient Satisfaction Survey
User satisfaction data collection for the IHS OIT NDW 0917-0036 Indian Health Service, Office of Information Technology, National Patient Reporting System National Data Warehouse Data Collection Survey
WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys 2, 1, 3, 4, 5, 6, 7, 8 Behavioral Health Patient Satisfaction Survey ,   Dental Patient Satisfaction Survey ,   Laboratory Patient Satisfaction Survey ,   Nutrition Services Patient Satisfaction Survey ,   Optometry Patient Satisfaction Survey ,   Pharmacy Patient Satisfaction Survey ,   Physcial Therapy Patient Satisfaction Survey ,   Radiology Patient Satisfaction Survey
We Care Survey, Blackfeet Community Hospital. 0917-0036 We Care Survey, Blackfeet Community Hospital.
We Care Survey, Fort Peck Service Unit Indian Health Service 0917-0036 We Care Survey, Fort Peck Service Unit Indian Health Service
We Care Survey, Fort Peck Service Unit Indian Health Service 0917-0036 We Care Survey, Fort Peck Service Unit, Indian Health Service
We Care Survey, Northern Cheyenne 0917-0036 We Care Patient Satisfaction Survey for Northern Cheyenne
WebTMA Survey 0917-0036 WebTMA Survey
White Earth Dental Clinic Patient Satisfaction Survey 0917-0036 White Earth Dental Clinic Patient Satisfaction Survey
Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey 0917-0036 Whiteriver Service Unit (WRSU) Birthing Center Patient Satisfaction Survey
eLearning Hands-on Customer Satisfaction Survey 0917-0036 eLearning Hands-on Customer Satisfaction survey
  Total Request 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 105,000 105,000 0 0 0 0
Annual Time Burden (Hours) 17,500 17,500 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$25,000
No
    Yes
    No
No
No
No
No
Evonne Bennett 301 443-4750
  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.
01/13/2022