Information Collection

State Medicaid official-telephone interview

IC 227605 under ICR 201707-0990-001 · OMB 0990-0461.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment E CCBHC Evaluation Baseline State Medicaid Official Interview_OMB.docx	Other-evaluation
Attachment G CCBHC Evaluation Midpoint State Medicaid Official Interview.docx	Other-interview
Attachment I CCBHC Evaluation End State Medicaid Official Interview.docx	Other-interview

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	Instrument File	Available Electronically?	Electronic Capability
Other-evaluation	Attachment E CCBHC Evaluation Baseline State Medicaid Official Interview_OMB.docx	No	Paper Only
Other-interview	Attachment G CCBHC Evaluation Midpoint State Medicaid Official Interview.docx	No	Paper Only
Other-interview	Attachment I CCBHC Evaluation End State Medicaid Official Interview.docx	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 8

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	48	48
Annual IC Time Burden (Hours)	48	48
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.