Information Collection

Direct Verification Evaluation Study

IC 181449 under ICR 200708-0584-004 · OMB 0584-0546.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
AppxB SA & Medicaid Interview Guides.pdf	Other-Interview Guide-SA CN & Medica
AppxC LEA Info Brochure.pdf	Other-Brochure-LEA
Appx E LEA Survey.pdf	Other-Survey-LEA
Appx F LEA Telephone Inverview.pdf	Other-Interview Guide-LEA
AppxD LEA Brochure Nonresponse.pdf	Other-Brochure

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-Interview Guide-SA CN & Medicaid	AppxB SA & Medicaid Interview Guides.pdf	No	Paper Only
Other-Brochure-LEA	AppxC LEA Info Brochure.pdf	No	Paper Only
Other-Survey-LEA	Appx E LEA Survey.pdf	No	Paper Only
Other-Interview Guide-LEA	Appx F LEA Telephone Inverview.pdf	No	Paper Only
Other-Brochure	AppxD LEA Brochure Nonresponse.pdf	No	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 364

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	639	639
Annual IC Time Burden (Hours)	379	379
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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