Information Collection

IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey

IC 235243 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⚠️ Notice: This information collection may be referencing outdated material.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 9017-0036 IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey	Form and Instruction
9017-0036 IHS CHR Survey IHS CHR Survey.docx	Form and Instruction
IHS CHR Evaluation Survey Submission short form.pdf IHS CHR Survey submission form	IC Document

IC Title:

IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey

Agency IC Tracking Number:

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	9017-0036	IHS CHR Survey	IHS CHR Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 325

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	325	325
Annual IC Time Burden (Hours)	108	108
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
IHS CHR Survey submission form	IHS CHR Evaluation Survey Submission short form.pdf	03/07/2019

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