Information Collection

Report administrative data - Private Sector

IC 209832 under ICR 201312-0970-003 · OMB 0970-0444.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0444 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VIB Household Rost Report administrative data - Private Sector	Form and Instruction
VIB Household Rost VIB Household Roster VIB Household Roster.pdf	Form and Instruction
VIC Administrative Data Elements.pdf VIC Administrative Data Elements	IC Document
VIA Standardized Instruments.pdf VIA Standardized Instruments	IC Document

IC Title:

Report administrative data - Private Sector

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR B (To search for a specific CFR, visit the Code of Federal Regulations.)

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	VIB Household Roster	VIB Household Roster	VIB Household Roster.pdf		No	No	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title: Records maintained on individuals

FR Citation: 5 FR 43

Number of Respondents: 9

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

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	18	18
Annual IC Time Burden (Hours)	2,592	2,592
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
VIC Administrative Data Elements	VIC Administrative Data Elements.pdf	12/09/2013
VIA Standardized Instruments	VIA Standardized Instruments.pdf	12/09/2013

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