Information Collection

Chinle Service Unit (CSU) Health Promotion/Disease Prevention

IC 231605 under ICR 201504-0917-007 · OMB 0917-0036.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0917-0036-58-3 Chinle Service Unit (CSU) Health Promotion/Disease Prevention	Form and Instruction
0917-0036-58-3 CSU Health Promotion survey CSU Health Promotion survey 5.17.18.docx	Form and Instruction
2018 HPDP Clearance Submission.docx HPDP Clearance Submission	IC Document

IC Title:

Chinle Service Unit (CSU) Health Promotion/Disease Prevention

Agency IC Tracking Number:

58-3

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	0917-0036-58-3	CSU Health Promotion survey	CSU Health Promotion survey 5.17.18.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,400

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,400	2,400
Annual IC Time Burden (Hours)	120	120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
HPDP Clearance Submission	2018 HPDP Clearance Submission.docx	05/30/2018

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