Information Collection

State, Local, and Tribal Government (CN Agency Staff, State Medicaid Agency Staff, Other State Agency Staff, and School District Staff)

IC 227121 under ICR 201904-0584-001 · OMB 0584-0630.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
A2 DCM-FRP Site Visit Scheduling Call.docx	Other-Appendix A-2 Site Visit Schedu
A3a DCM-FRP CN Site Visit Protocol.docx	Other-Appendix A-3a Detailed Site Vi
A3b DCM-FRP Medicaid Site Visit Protocol.docx	Other-Appendix A-3.b Detailed Site V
A3c DCM-FRP District Site Visit Protocol.docx	Other-Appendix A-3.c Detailed Site V
A4 DCM-FRP Site Visit Observation Protocol.docx	Other-Appendix A-4 Site Visit Observ
A6a DCM-FRP CN FollowUp Protocol.docx	Other-Appendix A.6a Detailed Follow-
A6b DCM-FRP Medicaid FollowUp Protocol.docx	Other-Appendix A-6.b Detailed Follow
A6c DCM-FRP District FollowUp Protocol.docx	Other-Appendix A-6.c Detailed Follow
B2 DCM-FRP Admin Records Request.docx	Other-Appendix B.2 Administrative Re
C2 DCM-FRP Cost Log Instructions.docx	Other-Appendix C-2 Instructions for
C3a DCM-FRP CN Cost Log.xlsx	Other-Appendix C-3.a State Cost Data
C3b DCM-FRP Medicaid Cost Log.xlsx	Other-Appendix C-3.b Medicaid State
C4 DCM-FRP Cost Log Clarification Protocol.docx	Other-Appendix C-4 State Cost Data C
A1 DCM-FRP_Site Visit Intro Letter.docx Appendix A.1 Site Visit Letter	IC Document
A2a Site Visit Materials_CN agency.docx Appendix A-2.a Site Visit Preparation: State Child Nutrition Agency	IC Document
A2b Site Visit Materials_Medicaid agency.docx Appendix A-2.b Site Visit Preparation: State Medicaid Agency	IC Document
A2c Site Visit Materials_District.docx Appendix A-2.c Site Visit Preparation: District	IC Document
A5 DCM-FRP Site Visit Follow Up Phone Interview Email.docx Appendix A.5 Site Visit Follow Up Telephone Interview Email	IC Document
B1 DCM-FRP Admin Records Request Emails.docx Appendix B.1 Administrative Records Request Emails	IC Document
C1 DCM-FRP Cost Log Emails.docx Appendix C-1 State Cost Data Collection Email	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

State, Local, and Tribal Government (CN Agency Staff, State Medicaid Agency Staff, Other State Agency Staff, and School District Staff)

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	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Appendix A-2 Site Visit Scheduling Call Protocol	A2 DCM-FRP Site Visit Scheduling Call.docx	No		Paper Only
Other-Appendix A-3a Detailed Site Visit Interview Protocol: State Child Nutrition Agency Staff	A3a DCM-FRP CN Site Visit Protocol.docx	No		Paper Only
Other-Appendix A-3.b Detailed Site Visit Interview Protocol: State Medicaid Agency Staff	A3b DCM-FRP Medicaid Site Visit Protocol.docx	No		Paper Only
Other-Appendix A-3.c Detailed Site Visit Interview Protocol: District Staff	A3c DCM-FRP District Site Visit Protocol.docx	No		Paper Only
Other-Appendix A-4 Site Visit Observation Protocol	A4 DCM-FRP Site Visit Observation Protocol.docx	No		Paper Only
Other-Appendix A.6a Detailed Follow-Up Telephone Interview Protocol: State Child Nutrition Agency Staff	A6a DCM-FRP CN FollowUp Protocol.docx	No		Paper Only
Other-Appendix A-6.b Detailed Follow-Up Telephone Interview Protocol: State Medicaid Agency Staff	A6b DCM-FRP Medicaid FollowUp Protocol.docx	No		Paper Only
Other-Appendix A-6.c Detailed Follow-Up Telephone Interview Protocol: District Staff	A6c DCM-FRP District FollowUp Protocol.docx	No		Paper Only
Other-Appendix B.2 Administrative Records Request	B2 DCM-FRP Admin Records Request.docx	Yes	No	Fillable Printable
Other-Appendix C-2 Instructions for State Cost Data Tracking Logs	C2 DCM-FRP Cost Log Instructions.docx	Yes	No	Fillable Printable
Other-Appendix C-3.a State Cost Data Tracking Logs	C3a DCM-FRP CN Cost Log.xlsx	Yes	No	Fillable Printable
Other-Appendix C-3.b Medicaid State Cost Data Tracking Logs	C3b DCM-FRP Medicaid Cost Log.xlsx	Yes	No	Fillable Printable
Other-Appendix C-4 State Cost Data Clarification Call	C4 DCM-FRP Cost Log Clarification Protocol.docx	No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title: FNS-8 USDA/FNS Studies and Reports

FR Citation: 56 FR 19078

Number of Respondents: 195

Number of Respondents for Small Entity: 96

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	Previously Approved
Annual Number of Responses for this IC	1,532	444	1,088
Annual IC Time Burden (Hours)	1,961	792	1,169
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix A.1 Site Visit Letter	A1 DCM-FRP_Site Visit Intro Letter.docx	06/16/2017
Appendix A-2.a Site Visit Preparation: State Child Nutrition Agency	A2a Site Visit Materials_CN agency.docx	06/16/2017
Appendix A-2.b Site Visit Preparation: State Medicaid Agency	A2b Site Visit Materials_Medicaid agency.docx	06/16/2017
Appendix A-2.c Site Visit Preparation: District	A2c Site Visit Materials_District.docx	06/16/2017
Appendix A.5 Site Visit Follow Up Telephone Interview Email	A5 DCM-FRP Site Visit Follow Up Phone Interview Email.docx	06/16/2017
Appendix B.1 Administrative Records Request Emails	B1 DCM-FRP Admin Records Request Emails.docx	04/03/2019
Appendix C-1 State Cost Data Collection Email	C1 DCM-FRP Cost Log Emails.docx	04/03/2019

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