Information Collection

Form IHS-912-2

IC 191425 under ICR 200911-0917-001 · OMB 0917-0030.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0030 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form IHS-912-2 Form IHS-912-2	Form
IHS-912-2 Request for Revocation of Restriction(s) IHS-912-2.pdf	Form
PROPOSEDINFOCOLLECTIONIHSFORMS6-24-09.pdf 60 Day Federal Register Notice	IC Document
30DAYIHSFORMS 11-20-09.pdf 30 Day Federal Register Notice	IC Document

IC Title:

Form IHS-912-2

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	IHS-912-2	Request for Revocation of Restriction(s)	IHS-912-2.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	833	833
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
60 Day Federal Register Notice	PROPOSEDINFOCOLLECTIONIHSFORMS6-24-09.pdf	11/12/2009
30 Day Federal Register Notice	30DAYIHSFORMS 11-20-09.pdf	11/25/2009

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