Information Collection

Tribal Electronic Health Record Data Call

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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-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 %

table that charts list of burden
	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

table that charts IC Documents
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.