Information Collection

Parents/Caregivers (who refused)

IC 199547 under ICR 201307-0925-004 · OMB 0925-0649.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 Parents/Caregivers (who refused)	Form and Instruction
4 Parents/Caregivers (who refuse) FINAL_HCS_SSA_ATTACH 8_PARENT REFUSAL PROTOCOL_Jan 2013.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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 and Instruction	4	Parents/Caregivers (who refuse)	FINAL_HCS_SSA_ATTACH 8_PARENT REFUSAL PROTOCOL_Jan 2013.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 880

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	880	77	803
Annual IC Time Burden (Hours)	147	10	137
Annual IC Cost Burden (Dollars)	0	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.