Information Collection

Medicaid Agencies

IC 218150 under ICR 201509-2528-001 · OMB 2528-0309.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2528-0309 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix B_Interview_Protocol_Medicaid_09102015.docx	Other-Interview Protocol

IC Title:

Medicaid Agencies

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	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Interview Protocol			Appendix B_Interview_Protocol_Medicaid_09102015.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 31 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	12	12
Annual IC Time Burden (Hours)	96	96
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.