View Information Collection Request (ICR) Package
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Certification
View Information Collection (IC) List
View Supporting Statement and Other Documents
Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0917-0040
ICR Reference No:
201811-0917-001
Status:
Historical Active
Previous ICR Reference No:
Agency/Subagency:
HHS/IHS
Agency Tracking No:
Title:
Indian Health Service Purchased/Referred Care Proof of Residency
Type of Information Collection:
New collection (Request for a new OMB Control Number)
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
03/22/2019
Retrieve Notice of Action (NOA)
Date Received in OIRA:
11/23/2018
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
03/31/2022
36 Months From Approved
Responses
77,185
0
0
Time Burden (Hours)
3,859
0
0
Cost Burden (Dollars)
0
0
0
Abstract:
The IHS Purchased/Referred Care Program needs this information to certify that the health care services requested and authorized by the IHS have been provided to individuals who documented to meet the eligibility requirements to receive medical services for Purchased/Referred Care provider(s). It is also to serve as a legal document for health and medical care authorized by IHS and rendered by health care providers under contract with the IHS.
Authorizing Statute(s):
PL:
Pub.L. 83 - 568 Part 1
Name of Law: Transfer Act
US Code:
42 USC 136
Name of Law: Indian Health
US Code:
25 USC 13
Name of Law: Synder Act
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
83 FR 13764
03/30/2018
30-day Notice:
Federal Register Citation:
Citation Date:
83 FR 48450
09/25/2018
Did the Agency receive public comments on this ICR?
Yes
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
IHS Proof of Residency Form
IHS-976
Purchased Referred Care Proof of Residency
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
77,185
0
0
77,185
0
0
Annual Time Burden (Hours)
3,859
0
0
3,859
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Miscellaneous Actions
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
This is a new information collection that will provide proof of residency in IHS operating areas. The increase is to collection data for this new collection.
Annual Cost to Federal Government:
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
Yes
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
Yes
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Evonne Bennett-Barnes 301 443-4750 evonne.bennett-barnes@ihs.gov
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
11/23/2018
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