CHIP and Medicaid Personnel

CHIPRA_ Children Health Insurance

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.