Information Collection

CHIP and Medicaid Personnel

IC 199535 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⚠️ Notice: This information collection may be referencing outdated material.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 A_Attachment H__Respondent Materials.pdf	Other-survey
0990-CHIP Part A_Attachment K_Site Visit Consent Procedure.pdf 0990-CHIP Part A_Attachment K_Site Visit Consent Procedure	IC Document

IC Title:

CHIP and Medicaid Personnel

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 A_Attachment H__Respondent Materials.pdf		No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

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	300	300
Annual IC Time Burden (Hours)	300	300
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
0990-CHIP Part A_Attachment K_Site Visit Consent Procedure	0990-CHIP Part A_Attachment K_Site Visit Consent Procedure.pdf	09/28/2011

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