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

Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: IHS Customer Service Satisfaction and Similar Surveys

Documents and Forms

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
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
IHS CHR Evaluation Survey Submission short form.pdf IHS CHR Survey submission form IC Document

Information Collection (IC) Details

IC Title:	IHS Impact Evaluation of Community Health Representative (CHR) Program Web-based Survey	Agency IC Tracking Number:

IC Status: Unchanged

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	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 %

	Requested	Previously Approved
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

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.