Information Collection

Medicaid and CHIP Officials

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.