Information Collection

CHIP Enrollees and Disenrollees

IC 199533 under ICR 201109-0990-002 · OMB 0990-0384.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0384 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-CHIP Part B_Attachment B1_CHIP Survey of Enrollees and Disenrollees.pdf	Other-survey
0990-CHIP Part A_Attachment B2_Data Elements and Question Sources.pdf	Other-source table

IC Title:

CHIP Enrollees and Disenrollees

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	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-survey			0990-CHIP Part B_Attachment B1_CHIP Survey of Enrollees and Disenrollees.pdf		No	No	Fillable Printable
Other-source table			0990-CHIP Part A_Attachment B2_Data Elements and Question Sources.pdf		No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15,000	15,000
Annual IC Time Burden (Hours)	7,500	7,500
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.