Information Collection

State OMBudsman Interview Protocol and Survey

IC 224903 under ICR 201612-0985-003 · OMB 0985-0055.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0985-0055 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 State Ombudsman Interview Protocol and Survey	Form
1 State Ombudsman Interview State-Ombudsmen-Interview-Protocol.doc	Form
2 State Ombudsmen Survey State-Ombudsmen-Survey.doc	Form

IC Title:

State Ombudsman Interview Protocol and 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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	State Ombudsman Interview	State-Ombudsmen-Interview-Protocol.doc		Yes	Yes	Fillable Fileable
Form	2	State Ombudsmen Survey	State-Ombudsmen-Survey.doc		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 53

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	53	53
Annual IC Time Burden (Hours)	98	98
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.