Information Collection

Medicaid and CHIP Officials

IC 202107 under ICR 201204-0990-004 · OMB 0990-0400.

Documents and Forms

Document Name Document Type
4.ATTACHMENT F.1.SCREEN SHOTS.HMA. 51 state survey form Q 8 and Q 13 only - example.docx Other-ATTACHMENT F.1.SCREEN SHOTS.HM
5.ATTACHMENT F.2. 51 state survey recruiting email text.docx Other-ATTACHMENT F.2. 51 state surve

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicaid and CHIP Officials	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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-ATTACHMENT F.1.SCREEN SHOTS.HMA. 51 state survey form Q 8 and Q 13 only - example			4.ATTACHMENT F.1.SCREEN SHOTS.HMA. 51 state survey form Q 8 and Q 13 only - example.docx		No		Printable Only
Other-ATTACHMENT F.2. 51 state survey recruiting email text			5.ATTACHMENT F.2. 51 state survey recruiting email text.docx		No		Printable Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 68	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	68	68
Annual IC Time Burden (Hours)	34	34
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.