Information Collection

Parents/Caregivers (who refused)

IC 199547 under ICR 201201-0925-002 · OMB 0925-0649.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0649 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Parents/Caregivers (who refused) Form and Instruction
1 Parents/Caregivers (who refused) REVISED_HCS_OMB_SSA_ATTACH 9_PARENT REFUSAL PROTOCOL_DEC 2011.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Parents/Caregivers (who refused)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Parents/Caregivers (who refused)	REVISED_HCS_OMB_SSA_ATTACH 9_PARENT REFUSAL PROTOCOL_DEC 2011.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 803	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	803	803
Annual IC Time Burden (Hours)	137	137
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.