Information Collection

IHS-912-2, Request for Revocation of Restriction(s)

IC 191425 under ICR 201301-0917-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 0917-0030-IHS-912- IHS-912-2, Request for Revocation of Restriction(s)	Form and Instruction
0917-0030-IHS-912- Request for Revocation of Restriction(s) IHS-912-2_508.pdf www.ihs.gov/CIO/PUF/	Form and Instruction

IC Title:

IHS-912-2, Request for Revocation of Restriction(s)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 and Instruction	0917-0030-IHS-912-2	Request for Revocation of Restriction(s)	IHS-912-2_508.pdf	http://www.ihs.gov/CIO/PUF/	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: IHS Privacy Act system notice 09 17 0001, IHS Medical, Health and Billing Records

FR Citation: 75 FR 1625

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	Previously Approved
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
No associated records found

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