Information Collection

A Scan of the Status of States' Integration of Human Services and Health Insurance Programs

IC 220612 under ICR 201403-0990-004 · OMB 0990-0421.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0421 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-0421Attachment A_Questionnaire and Instructions_state integration 3_14_16.docx	Other-survey
0990-0421 SS_A_ASPE Generic_state integration 3_14_16.docx A Scan of the Status of States’ Integration of Human Services and Health Insurance Programs	IC Document
0990-0421SS_B_ASPE Generic_state integration 3_14_16.docx A Scan of the Status of States’ Integration of Human Services and Health Insurance Programs	IC Document
0990-0421Cover Sheet_ASPE Generic_state integration 3_14_16.docx A Scan of the Status of States’ Integration of Human Services and Health Insurance Programs	IC Document
0990-0421Attachment C_email with link to respondents_state integration 3_14_16.docx EMAIL_A Scan of the Status of States’ Integration of Human Services and Health Insurance Programs	IC Document
0990-0421Attachment B_letter to respondents_state integration 3_14_16.docx A Scan of the Status of States’ Integration of Human Services and Health Insurance Programs	IC Document
0990-0421Attachment D_APHSA letter to respondents_state integration 3_14_16.docx A Scan of the Status of States’ Integration of Human Services and Health Insurance Programs	IC Document

IC Title:

A Scan of the Status of States' Integration of Human Services and Health Insurance Programs

Agency IC Tracking Number:

IC Status: New

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
Other-survey			0990-0421Attachment A_Questionnaire and Instructions_state integration 3_14_16.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 92

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	46	46
Annual IC Time Burden (Hours)	35	35
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
A Scan of the Status of Statesâ Integration of Human Services and Health Insurance Programs	0990-0421 SS_A_ASPE Generic_state integration 3_14_16.docx	03/14/2016
A Scan of the Status of Statesâ Integration of Human Services and Health Insurance Programs	0990-0421SS_B_ASPE Generic_state integration 3_14_16.docx	03/14/2016
A Scan of the Status of Statesâ Integration of Human Services and Health Insurance Programs	0990-0421Cover Sheet_ASPE Generic_state integration 3_14_16.docx	03/14/2016
EMAIL_A Scan of the Status of Statesâ Integration of Human Services and Health Insurance Programs	0990-0421Attachment C_email with link to respondents_state integration 3_14_16.docx	03/14/2016
A Scan of the Status of Statesâ Integration of Human Services and Health Insurance Programs	0990-0421Attachment B_letter to respondents_state integration 3_14_16.docx	03/14/2016
A Scan of the Status of Statesâ Integration of Human Services and Health Insurance Programs	0990-0421Attachment D_APHSA letter to respondents_state integration 3_14_16.docx	03/14/2016

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