Information Collection

State Medicaid Tobacco Coverage Survey

IC 7160 under ICR 200902-0920-001 · OMB 0920-0691.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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-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 %

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)	26	26
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.