U.S. Department of Health and Human Services
Indian Health Service: The Federal Health Program for American Indians and Alaska Natives
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Step 1 - Best and Promising Practice and Local Effort Electronic Submission Form

FORM APPROVED
OMB Approval No. 0917-0034
Exp. Date 1-31-2016

To submit a best practice, promising practice, local effort, resource, or policy, please complete the inventory form below. Your submission won’t be saved until you complete all the required fields and click the Submit button at the end of Step 3. At the end of the form, you will have an opportunity to preview and edit your submission before sending it to the database.

* Indicates a Required Field

* 1. Please provide the name, title and contact information for the person filling in this template.

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*  2. Should people reviewing your submission contact someone other than yourself for questions about the program?

By submitting this form you are agreeing that you or your designee can be contacted regarding this submission.

Public Burden Statement: In accordance with Paperwork Reduction Act (5 CFR 1320.8 (b)(3), a Federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Respondents must be informed (on the reporting instrument, in instructions, or in a cover letter) the reasons for which the information will be collected; the way the information will be used to further the proper performance of the functions of the agency; whether responses to the collection of the information are voluntary, required to obtain a benefit (citing authority), or mandatory (citing authority); and the nature and extent of confidentiality to be provided, if any (citing authority). Public reporting burden for this collection of information is estimated to average 20 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the necessary data, and completing and reviewing the collection information. Send comments regarding the burden estimate or any other aspect of this collection of information to the IHS PRA Information Collection Clearance Staff, 801 Thompson Ave., Suite 450, Rockville, MD 20852.