Information Collection

Evaluation of the Illinois and Wisconsin State Pharmacy Assistance Waivers

IC 8739 under ICR 200307-0938-001 · OMB 0938-0902.

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Information Collection (IC) Details

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IC Title:	Evaluation of the Illinois and Wisconsin State Pharmacy Assistance Waivers	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	CMS-10087				Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,200	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	2,200	2,200
Annual IC Time Burden (Hours)	550	550
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.