Information Collection

MFH Caregiver Survey

IC 223587 under ICR 201403-2900-007 · OMB 2900-0770.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0770 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
FINAL - MFH Caregiver cover and survey.docx	Other-Survey
FINAL - MFH Caregiver Clearance Submission Template.doc MFH Caregiver Generic Request	IC Document

IC Title:

MFH Caregiver Survey

Agency IC Tracking Number:

2900-0770

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			FINAL - MFH Caregiver cover and survey.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 700

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	700	700
Annual IC Time Burden (Hours)	58	58
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
MFH Caregiver Generic Request	FINAL - MFH Caregiver Clearance Submission Template.doc	09/19/2016

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