Information Collection

Barriers to Care Survey

IC 220449 under ICR 201702-0920-002 · OMB 0920-1133.

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
Philadelphia Barriers to Care Survey (modified February Att7_PA Barr_to_care_02102017.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Philadelphia Barriers to Care Survey (modified February 2017)	Att7_PA Barr_to_care_02102017.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	Previously Approved
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.