Information Collection

Safety Net Consumer Survey Round 1

IC 200138 under ICR 201208-0915-006 · OMB 0915-0347.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Safety Net Consumer Survey Round 1	Form
1 Safety Net Consumer Survey R1 Round1 HPP Survey 08_16_2012.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Form	1	Safety Net Consumer Survey R1	Round1 HPP Survey 08_16_2012.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 960

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	960	960
Annual IC Time Burden (Hours)	317	317
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.