Information Collection

IHS Community Health Representative Basic Training & Refresher Course Training form

IC 216452 under ICR 201804-0917-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 IHS Community Health Representative Basic Training & Refresher Course Training form	Form and Instruction
0917-0036 IHS Community Health Representative Basic Training & Ref OMB No. 0917-0036-15, CHR Basic Training and Refresher Training Evaluation Form.docx	Form and Instruction
OMB 0917-0036 Mini-Supporting Statement.docx OMB No. 0917-0036, Mini-Supporting Statement for IHS Community Health Representative Basic Training & Refresher Course Training	IC Document

IC Title:

IHS Community Health Representative Basic Training & Refresher Course Training form

Agency IC Tracking Number:

IC Status: Removed

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	IHS Community Health Representative Basic Training & Refresher Course Training form	OMB No. 0917-0036-15, CHR Basic Training and Refresher Training Evaluation Form.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

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: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-180	180
Annual IC Time Burden (Hours)	-15	15
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
OMB No. 0917-0036, Mini-Supporting Statement for IHS Community Health Representative Basic Training & Refresher Course Training form	OMB 0917-0036 Mini-Supporting Statement.docx	05/06/2015

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