Information Collection

Evaluation of the Oregon Medicaid Reform Demonstration: Adult Interview, Child Interview, Pediatric Asthma Interview, Insulin- Dependent Diabetes Interview, Low Back Pain Interview Medical....

IC 8353 under ICR 199709-0938-014 · OMB 0938-0710.

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Information Collection (IC) Details

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IC Title:	Evaluation of the Oregon Medicaid Reform Demonstration: Adult Interview, Child Interview, Pediatric Asthma Interview, Insulin- Dependent Diabetes Interview, Low Back Pain Interview Medical....	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-R-192				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,533	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,533	5,533
Annual IC Time Burden (Hours)	2,242	2,242
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

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