Information Collection

State, Local County SNAP Agencies

IC 192366 under ICR 201003-0584-004 · OMB 0584-0557.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix G -ELECTRONIC SURVEY.doc	Other-Electronic Survey Screen Shots
Appendix K - SNAP Staff Phone Interview.doc	Other-Telephone Interview
Appendix E - Request for Performance Data.doc	Instruction
Appendix F - Survey Access Instructions.doc	Instruction
Non-Response Placeholder.doc	Other-Non Response Placeholder
Appendix H - SURVEY REMINDER CALL SCRIPT.doc Appendix H: SURVEY REMINDER CALL SCRIPT	IC Document
Appendix I - PHONE INTERVIEW SCHEDULING CALL SCRIPT.doc Appendix I: PHONE INTERVIEW SCHEDULING CALL SCRIPT	IC Document
Appendix J - PERFORMANCE DATA REMINDER CALL.doc Appendix J: PERFORMANCE DATA REMINDER CALL	IC Document
Appendix M - SITE VISIT INTERVIEW TOPICS.doc Appendix M - SITE VISIT INTERVIEW TOPICS	IC Document
Appendix B - RESPONDENT INVITATION LETTERS.doc Appendix B - RESPONDENT INVITATION LETTERS	IC Document

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Electronic Survey Screen Shots	www.SNAP.mathematica-mpr.com	Yes	Yes	Fillable Fileable Signable
Other-Telephone Interview		No		Paper Only
Instruction		No		Paper Only
Instruction	www.SNAP.mathematica-mpr.com	Yes	No	Paper Only
Other-Non Response Placeholder		No		Paper Only

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 451

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 55 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,669	1,669
Annual IC Time Burden (Hours)	2,677	2,677
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix H: SURVEY REMINDER CALL SCRIPT		03/29/2010
Appendix I: PHONE INTERVIEW SCHEDULING CALL SCRIPT		03/29/2010
Appendix J: PERFORMANCE DATA REMINDER CALL		03/29/2010
Appendix M - SITE VISIT INTERVIEW TOPICS		03/29/2010
Appendix B - RESPONDENT INVITATION LETTERS		03/29/2010

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

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