Information Collection

20152 CHIME-Comparing Health Insurance Measurement Error

IC 216180 under ICR 201501-0607-005 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
advanceletter_MedicaFinal_v2 (4-8-15).pdf	Other-Invitation to participate
chime questionnaire FINAL.doc	Other-CHIME March 2015 Draft Questio
chime questionnaire v9.doc	Other-CHIME March 2015 Draft Questio
white_paper_v8.doc	Other-Attachment A

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Invitation to participate	advanceletter_MedicaFinal_v2 (4-8-15).pdf	Yes	Yes	Paper Only
Other-CHIME March 2015 Draft Questionnaire	chime questionnaire FINAL.doc	Yes	Yes	Paper Only
Other-CHIME March 2015 Draft Questionnaire	chime questionnaire v9.doc	Yes	Yes	Paper Only
Other-Attachment A	white_paper_v8.doc	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

Number of Respondents for Small Entity: 5,000

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	1,083	1,083
Annual IC Cost Burden (Dollars)	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.