Information Collection

IHS-912-1, Request for Restriction(s)

IC 191424 under ICR 202309-0917-001 · OMB 0917-0030.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form IHS 912-1 IHS-912-1, Request for Restriction(s)	Form and Instruction
IHS 912-1 Request for Restriction(s) IHS-912-1_508 - 2023.docx	Form and Instruction
IHS 912-1 Request for Restriction(s) IHS-912-1_508 - 2023.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

IHS 912-1

Is this a Common Form? No

IC Status: Modified

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	IHS 912-1	Request for Restriction(s)	IHS-912-1_508 - 2023.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: IHS Privacy Act system notice 09 17 0001, IHS Medical, Health and Billing Records

FR Citation: 75 FR 1625

Number of Respondents: 214

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	214	214
Annual IC Time Burden (Hours)	36	36
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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