Information Collection

Tribal Electronic Health Record Data Call

IC 247212 under ICR 202105-0917-001 · OMB 0917-0042.

Documents and Forms

Document Name Document Type
Form 0917-xxxx Tribal Electronic Health Record Data Call Form and Instruction
0917-xxxx EHR Data Call Tab C - IHS Congressional Tribal EHR Data Call Template Final 4.29.21.xlsx Form and Instruction
Tab B - Tribal EHR Data Call - Supporting_Statement OMB template final 4.29.21.docx Supporting Statement IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Tribal Electronic Health Record Data Call	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0917-xxxx	EHR Data Call	Tab C - IHS Congressional Tribal EHR Data Call Template Final 4.29.21.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	40	40
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	Tab B - Tribal EHR Data Call - Supporting_Statement OMB template final 4.29.21.docx	05/04/2021

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