Information Collection

State and Local Agencies

IC 197621 under ICR 201105-0584-001 · OMB 0584-0561.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0584-0561 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix F1.docm	Other-Round 1 Massachusetts Executiv
Appendix F2.docm	Other-Round 2 Massachusetts Executiv
Appendix F3.docm	Other-Round 3 Massachusetts Executiv
Appendix F4.docm	Other-Round 1 DTA Staff HIP Intervie
Appendix F5.docm	Other-Round 2 DTA Staff HIP Intervie
Appendix F6.docm	Other-Round 3 DTA Staff HIP Intervie
Appendix F7.docm	Other-Round 1 DTA Technical Team HIP
Appendix F8.docm	Other-Round 2 DTA Technical Team HIP
Appendix F9.docm	Other-Round 3 DTA Technical Team HIP
Appendix F10.docm	Other-Round 1 Local Office Interview
Appendix F11.docm	Other-Round 2 Local Office Interview
Appendix F12.docm	Other-Round 3 Local Office Interview

IC Title:

State and Local Agencies

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-Round 1 Massachusetts Executive Interview Guide	Appendix F1.docm	No	Paper Only
Other-Round 2 Massachusetts Executive Interview Guide	Appendix F2.docm	No	Paper Only
Other-Round 3 Massachusetts Executive Interview Guide	Appendix F3.docm	No	Paper Only
Other-Round 1 DTA Staff HIP Interview Guide	Appendix F4.docm	No	Paper Only
Other-Round 2 DTA Staff HIP Interview Guide	Appendix F5.docm	No	Paper Only
Other-Round 3 DTA Staff HIP Interview Guide	Appendix F6.docm	No	Paper Only
Other-Round 1 DTA Technical Team HIP Interview Guide	Appendix F7.docm	No	Paper Only
Other-Round 2 DTA Technical Team HIP Interview Guide	Appendix F8.docm	No	Paper Only
Other-Round 3 DTA Technical Team HIP Interview Guide	Appendix F9.docm	No	Paper Only
Other-Round 1 Local Office Interview Guide	Appendix F10.docm	No	Paper Only
Other-Round 2 Local Office Interview Guide	Appendix F11.docm	No	Paper Only
Other-Round 3 Local Office Interview Guide	Appendix F12.docm	No	Paper Only

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 17

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	17	17
Annual IC Time Burden (Hours)	24	24
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.