Information Collection

Chinle Event Survey

IC 260896 under ICR 202201-0917-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 0917-0036-134 Event Survey Chinle Event Survey	Form and Instruction
0917-0036-134 Event Survey Event Survey_6.26.23 (002).docx	Form and Instruction
Generic Clearance Submission Template_ Event Survey 6.26.2023.docx Generic Template	IC Document
Event Survey_Federal Cost Estimate_6.26.2023.docx Cost Estimate	IC Document

IC Title:

Chinle Event Survey

Agency IC Tracking Number:

134

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	0917-0036-134				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 250

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Template		06/28/2023
Cost Estimate		06/28/2023

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

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