Telephone Interview Discussion Guide

Children's Health Insurance Program Reauthorization Act (CHIPRA) 10-State Evaluation, Telephone Interviews with State CHIP Program Administrators

Documents and Forms

Document Name Document Type
Attachment B2_Fact Sheet Template.docx Other-Fact Sheet
Attachment B1_Discussion Guide.docx Other-Discussion Guide
Attachment D1_State Letter.docx State Letter IC Document
Attachment E_Design Report.pdf Design Report IC Document
Attachment D2_Consent Form_Nov 12 2012.docx Attachment D2_Consent Form_Nov 12 2012 IC Document

Information Collection (IC) Details

IC Title:	Telephone Interview Discussion Guide	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-Fact Sheet			Attachment B2_Fact Sheet Template.docx		No	No	Paper Only
Other-Discussion Guide			Attachment B1_Discussion Guide.docx		No		Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 77	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	77	77
Annual IC Time Burden (Hours)	77	77
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
State Letter	Attachment D1_State Letter.docx	08/08/2012
Design Report	Attachment E_Design Report.pdf	08/08/2012
Attachment D2_Consent Form_Nov 12 2012	Attachment D2_Consent Form_Nov 12 2012.docx	11/15/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.