IHS Forms To Implement The Privacy Rule (45 CFR Parts 160 and 164)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form IHS-917 IHS Forms To Implement The Privacy Rule (45 CFR Parts 160 and 164)	Form and Instruction	Modified	Available
SupportingStatement2006.wpd	Supporting Statement A	Uploaded 2006-08-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6589	IHS Forms To Implement The Privacy Rule (45 CFR Parts 160 and 164)	Form and Instruction	Modified

ICR Details

OMB Control No: 0917-0030	ICR Reference No: 200608-0917-002
Status: Historical Active	Previous ICR Reference No: 200304-0917-001
Agency/Subagency: HHS/IHS	Agency Tracking No:
Title: IHS Forms To Implement The Privacy Rule (45 CFR Parts 160 and 164)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/01/2006
	Date Received in OIRA: 08/28/2006
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2009	36 Months From Approved	10/31/2006
Responses	542,500	0	542,500
Time Burden (Hours)	5,425	0	174,375
Cost Burden (Dollars)	0	0	0

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Abstract: This is a request for a extension of a currently approved collection. This collection of information is made necessary by the DHHS Rule entitled "Standards for Privacy of Individually Identifiable Health Information" ("Privacy Rule") (456 CFR Parts 160 and 164). Considered a covered entity under the Privacy Rule, the IHS is subject to the Rule and must develop and implement methods to meet the information collection requirements contained in the rule.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: Statute at Large: 42 Stat. 1320 Name of Statute: null

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 31195	06/01/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 45834	08/10/2006
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
IHS Forms To Implement The Privacy Rule (45 CFR Parts 160 and 164)	IHS-917, IHS912-1, IHS-810, IHS912-2, IHS-913	Request for Correction ,   Auth. use/disclosure hlth info. ,   Request for Restrictions ,   Request for Revocation of Restr. ,   Req. for an Acct. of Disclosures

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ICR Summary of Burden

table that charts list of burden

	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	542,500	542,500	0	0	0	0
Annual Time Burden (Hours)	5,425	174,375	0	-168,950	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Cutting Redundancy

Short Statement: The burden is less because the forms were mildly edited to ease the burden of each patient. Redundancy was eleminated.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 08/28/2006

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