IHS Community Health Representative Basic Training & Refresher Training

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0036 can be found here:

Documents and Forms

Document Name Document Type
Form 0917-0036-15 IHS Community Health Representative Basic Training & Refresher Training Form and Instruction
0917-0036-15 OMB Form No., 0917-0036-15, IHS community Health Represe OMB No. 0917-0036-15, CHR Basic Training and Refresher Training Evaluation Form.docx Form and Instruction
OMB 0917-0036-15 Mini-Supporting Statement.docx OMB No. 0917-0036-15 IC Document
Signed OMB No. 0917-0036-15.pdf OMB 0917-0036-15 Mini-Supporting Statement (signed) IC Document

Information Collection (IC) Details

IC Title:	IHS Community Health Representative Basic Training & Refresher Training	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 25 CFR Sec. 1616(a)(1) and (b)(3) (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0917-0036-15	OMB Form No., 0917-0036-15, IHS community Health Representative (CHR) Basic and Refresher Training	OMB No. 0917-0036-15, CHR Basic Training and Refresher Training Evaluation Form.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 180	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	180	0	0	0	0	0
Annual IC Time Burden (Hours)	15	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
OMB No. 0917-0036-15	OMB 0917-0036-15 Mini-Supporting Statement.docx	12/10/2012
OMB 0917-0036-15 Mini-Supporting Statement (signed)	Signed OMB No. 0917-0036-15.pdf	12/11/2012

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