Information Collection

State official responsible for administering the Medicaid Program

IC 181792 under ICR 200708-0990-003 · OMB 0990-0320.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-Homelessness Data - Survey 1 (Medicaid - do include) 8-9-2007.doc	Other-Medicaid Survey
0990-Homelessness Data - Survey 2 (Medicaid - do not include) 8-9-2007.doc	Other-Medicaid Survey

IC Title:

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Medicaid Survey					No	No	Paper Only
Other-Medicaid Survey					No	No	Paper Only

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

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	51	51
Annual IC Time Burden (Hours)	51	51
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.

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