Information Collection

IHS-843-1A, Order for Health Services

IC 205728 under ICR 201302-0917-001 · OMB 0917-0002.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OMB No. 0917-0002, IHS-843-1A, Order for Health Services	Form and Instruction
OMB No. 0917-0002, OMB No. 0917-0002, IHS 843-1A, Order for Health Service Final IHS-843-1A_Order_For_Health_Services_FORM Double-sided 5 pages-Jan 15-2013 (2).doc www.ihs.gov/puf/	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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	OMB No. 0917-0002, IHS 843-1A	OMB No. 0917-0002, IHS 843-1A, Order for Health Service	Final IHS-843-1A_Order_For_Health_Services_FORM Double-sided 5 pages-Jan 15-2013 (2).doc	http://www.ihs.gov/puf/	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

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: 7,977

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	414,804	393,781	21,023
Annual IC Time Burden (Hours)	20,740	19,689	1,051
Annual IC Cost Burden (Dollars)	0	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.