Information Collection

Safety Net Consumer Survey Round 2

IC 200139 under ICR 201208-0915-006 · OMB 0915-0347.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Safety Net Consumer Survey Round 2	Form
2 R2 HPP Survey Revised Jan 2012 Access Questions R2 HPP Survey Revised Jan 2012 Access Questions.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	2	R2 HPP Survey Revised Jan 2012 Access Questions	R2 HPP Survey Revised Jan 2012 Access Questions.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 768

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	768	768
Annual IC Time Burden (Hours)	253	253
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.