Information Collection

Parents and Other Family Members of Children

IC 199536 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
0990-CHIP Part A_Attachment D2_Focus Group Moderator Guide for Parents of CHIP Enrollees.pdf Other-focus
0990-CHIP Part A_Attachment D3_Focus Group Moderator Guide for Parents of CHIP Disenrollees.pdf Other-focus
0990-CHIP Part A_Attachment D1_Focus Group_Moderator Guide for Parents with Employer Insurance.pdf Other-focus
0990-CHIP Part A_Attachment D4_Focus Group Moderator Guide for Parents of Eligible but Uninsured.pdf Other-survey
0990-CHIP Part A_Attachment I2_Focus Group Consent Form for Parents of CHIP Disenrollees.pdf 0990-CHIP Part A_Attachment I2_Focus Group Consent Form for Parents of CHIP Disenrollees IC Document
0990-CHIP Part A_Attachment I3_Focus Group Consent Form for Parents of Eligible but Uninsured.pdf 0990-CHIP Part A_Attachment I3_Focus Group Consent Form for Parents of Eligible but Uninsured IC Document
0990-CHIP Part A_Attachment I4_Focus Group Consent Form for Parents of Children Covered by Employer-Sponsored Insurance.pdf 0990-CHIP Part A_Attachment I4_Focus Group Consent Form for Parents of Children Covered by Employer-Sponsored Insurance IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Parents and Other Family Members of Children	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-focus	0990-CHIP Part A_Attachment D1_Focus Group_Moderator Guide for Parents with Employer Insurance.pdf	No	No	Paper Only
Other-survey	0990-CHIP Part A_Attachment D4_Focus Group Moderator Guide for Parents of Eligible but Uninsured.pdf	No	No	Paper Only
Other-focus	0990-CHIP Part A_Attachment D2_Focus Group Moderator Guide for Parents of CHIP Enrollees.pdf	No	No	Paper Only
Other-focus	0990-CHIP Part A_Attachment D3_Focus Group Moderator Guide for Parents of CHIP Disenrollees.pdf	No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 80	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	80	80
Annual IC Time Burden (Hours)	160	160
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
0990-CHIP Part A_Attachment I2_Focus Group Consent Form for Parents of CHIP Disenrollees	0990-CHIP Part A_Attachment I2_Focus Group Consent Form for Parents of CHIP Disenrollees.pdf	09/28/2011
0990-CHIP Part A_Attachment I3_Focus Group Consent Form for Parents of Eligible but Uninsured	0990-CHIP Part A_Attachment I3_Focus Group Consent Form for Parents of Eligible but Uninsured.pdf	09/28/2011
0990-CHIP Part A_Attachment I4_Focus Group Consent Form for Parents of Children Covered by Employer-Sponsored Insurance	0990-CHIP Part A_Attachment I4_Focus Group Consent Form for Parents of Children Covered by Employer-Sponsored Insurance.pdf	09/28/2011

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