State Medicaid Tobacco Coverage Survey

Documents and Forms

Document Name Document Type
Att-3a. State Medicaid Tobacco Dependence Survey 2009.pdf Other-WORD
Att-3b. Proposed Changes to Tobacco Survey.doc Att-3b IC Document
Att-4. Cover Email for Survey.doc Att-4 IC Document
Att-5. Thank You Email for Survey.doc Att-5 IC Document
Att-6. Cover Email for Feedback Report.doc Att-6 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State Medicaid Tobacco Coverage Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Other-WORD			Att-3a. State Medicaid Tobacco Dependence Survey 2009.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

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: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	26	26
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att-3b	Att-3b. Proposed Changes to Tobacco Survey.doc	01/16/2009
Att-4	Att-4. Cover Email for Survey.doc	01/16/2009
Att-5	Att-5. Thank You Email for Survey.doc	01/16/2009
Att-6	Att-6. Cover Email for Feedback Report.doc	01/16/2009

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