Information Collection

2017 1024 Medicaid.gov first draft questionnaire 6.5.17

IC 227406 under ICR 201412-1090-002 · OMB 1090-0008.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1090-0008 can be found here:

Documents and Forms

Document Name Document Type
Form 1024 2017 1024 Medicaid.gov first draft questionnaire 6.5.17 Form and Instruction
1024 2017 1024 Medicaid.gov first draft questionnaire 6.5.17 2017 1024 Medicaid.gov first draft questionnaire 6.5.17.xlsx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	2017 1024 Medicaid.gov first draft questionnaire 6.5.17	Agency IC Tracking Number:	1024

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
Form and Instruction	1024	2017 1024 Medicaid.gov first draft questionnaire 6.5.17	2017 1024 Medicaid.gov first draft questionnaire 6.5.17.xlsx		Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,600	3,600
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.