Information Collection

Barriers to Care Survey

IC 220449 under ICR 201603-0920-004 · OMB 0920-1133.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1133 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Barriers to Care Survey	Form and Instruction
MA Barriers to Care Survey Att 5_Mass Barriers to Care Survey.docx	Form and Instruction
CT Barriers to Care Survey Att 6_Conn Barriers to Care Survey.docx	Form and Instruction
Phila Barriers to Care Survey Att 7_Phil Barriers to Care Survey.docx	Form and Instruction

IC Title:

Barriers to Care Survey

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	MA Barriers to Care Survey	Att 5_Mass Barriers to Care Survey.docx	Yes	Yes	Fillable Fileable
Form and Instruction	none	CT Barriers to Care Survey	Att 6_Conn Barriers to Care Survey.docx	Yes	Yes	Fillable Fileable
Form and Instruction	none	Phila Barriers to Care Survey	Att 7_Phil Barriers to Care Survey.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	1,200	1,200
Annual IC Time Burden (Hours)	600	600
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.