OMB Form No. 0917-0036, Indian Health Service (IHS) Community Health Representative (CHR) Basic Online Training Evaluation

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0036 can be found here:

Documents and Forms

Document Name Document Type
Form 0917-0036 OMB Form No. 0917-0036, Indian Health Service (IHS) Community Health Representative (CHR) Basic Online Training Evaluation Form and Instruction
0917-0036 IHS CHR Basic Online Training Evaluation OMB No 0917-0036-15 CHR Basic Online Training Evaluation Form (002).docx Form and Instruction
OMB 0917-0036 Mini-Supporting Statement Basic Online Training Evaluation (003).docx Supporting Statement for OMB Form No. 0917-0036, Indian Health Service (IHS) Community Health Representative (CHR) Basic Online IC Document

Information Collection (IC) Details

IC Title:	OMB Form No. 0917-0036, Indian Health Service (IHS) Community Health Representative (CHR) Basic Online Training Evaluation	Agency IC Tracking Number:	59

IC Status: New

Obligation to Respond: Mandatory

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	0917-0036	IHS CHR Basic Online Training Evaluation	OMB No 0917-0036-15 CHR Basic Online Training Evaluation Form (002).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 300	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement for OMB Form No. 0917-0036, Indian Health Service (IHS) Community Health Representative (CHR) Basic Online Training Evaluation	OMB 0917-0036 Mini-Supporting Statement Basic Online Training Evaluation (003).docx	11/12/2015

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