Information Collection

Family/Public Medical Program Evaluation

IC 198885 under ICR 201201-0920-005 · OMB 0920-0901.

Documents and Forms

Document Name Document Type
Att C16 Family Pub Prog Eval -Medical.docx Other-WORD

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Family/Public Medical Program Evaluation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 241, Sec 301 42 CFR 247b-4, Sec 317C (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD			Att C16 Family Pub Prog Eval -Medical.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 51 FR 42449

Number of Respondents: 250	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	8	8
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.