Request for an Extension Instrument Scope

Request for an Extension Instrument

Name of Instrument

Request for an Extension

Scope of Instrument

This instrument collects:

• Personally identifiable information from the individual submitting request

• Relevant facility information

• Relevant information to request for an extension

Example of DHS Forms used within the scope of this instrument

Attached is DHS Form 9036 that is used to standardize the collection of information within this instrument. DHS Form 9036 identifies most, but not all of the data routinely collected under this instrument.

1