Request for Redetermination 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