Information Collection

Phase 1 Enrollment Survey B

IC 218945 under ICR 201811-0920-002 · OMB 0920-1100.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1100 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Phase 1 Enrollment Survey B	Form and Instruction
Phase 1 Enrollment Survey B (English) Att 7a_Phase 1 Enrollment Survey B (English).docx	Form and Instruction
Phase 1 Enrollment Survey B (Spanish) Att 7b_Phase 1 Enrollment Survey B (Spanish).docx	Form and Instruction
Phase 1 Enrollment Survey B (screen shots) Att 12a_Screenshots_Phase 1 Enrollment Survey B.pdf	Form and Instruction
Phase 1 Enrollment Survey B (screen shots in Spanish) Att 12b_Screenshots_Phase1 Enrollment Survey B (Spanish).pdf	Form and Instruction

IC Title:

Phase 1 Enrollment Survey B

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	n/a	Phase 1 Enrollment Survey B (English)	Att 7a_Phase 1 Enrollment Survey B (English).docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Phase 1 Enrollment Survey B (Spanish)	Att 7b_Phase 1 Enrollment Survey B (Spanish).docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Phase 1 Enrollment Survey B (screen shots)	Att 12a_Screenshots_Phase 1 Enrollment Survey B.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Phase 1 Enrollment Survey B (screen shots in Spanish)	Att 12b_Screenshots_Phase1 Enrollment Survey B (Spanish).pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 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	200	200
Annual IC Time Burden (Hours)	200	200
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.