Information Collection

24 month Followup survey California and Texas

IC 223049 under ICR 201604-0990-002 · OMB 0990-0424.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Instrument 1- CA_24 Month Followup Survey.docx	Other-survey
Instrument 2- TX_24 Month Followup Survey.docx	Other-survey
Attachment A_ Overview of the PAF Evaluation_FU.docx Overview of the PAF	IC Document
Attachment B_Question by Question Source Table for the PAF Follow Up.docx Source Table	IC Document
Attachment C_Sources Referenced for PAF Follow Up.docx Sources Referenced	IC Document
Attachment D_Persons Consulted.docx Person Consulted	IC Document
Attachment F_PAF Analysis Plan for Impact Study_FU.docx PAF Analysis Plan	IC Document

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	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-survey			Instrument 1- CA_24 Month Followup Survey.docx		Yes	Yes	Fillable Fileable
Other-survey			Instrument 2- TX_24 Month Followup Survey.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 505

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	505	505
Annual IC Time Burden (Hours)	253	253
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Overview of the PAF	Attachment A_ Overview of the PAF Evaluation_FU.docx	08/16/2016
Source Table	Attachment B_Question by Question Source Table for the PAF Follow Up.docx	08/16/2016
Sources Referenced	Attachment C_Sources Referenced for PAF Follow Up.docx	08/16/2016
Person Consulted	Attachment D_Persons Consulted.docx	08/16/2016
PAF Analysis Plan	Attachment F_PAF Analysis Plan for Impact Study_FU.docx	08/16/2016

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