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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of instruments
Document Type	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-focus	No	No	Paper Only
Other-focus	No	No	Paper Only
Other-focus	No	No	Paper Only
Other-survey	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 %

table that charts list of burden
	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

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

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

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