Information Collection

CHIP/Medicaid Enrollees and Disenrollees

IC 199533 under ICR 201110-0990-006 · OMB 0990-0384.

Documents and Forms

Document Name Document Type
0990-CHIP Part B_Attachment B1_CHIP Survey of Enrollees and Disenrollees.pdf Other-survey

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CHIP/Medicaid Enrollees and Disenrollees	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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 B_Attachment B1_CHIP Survey of Enrollees and Disenrollees.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 19,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	19,500	19,500
Annual IC Time Burden (Hours)	9,750	9,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.