Information Collection

1. MUSE Caregiver Enrollment Form 7.9.18_CLEAN

IC 232416 under ICR 201912-0970-007 · OMB 0970-0521.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0521 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
1. MUSE Caregiver Enrollment Form FINAL_1.17.2019.pdf	Other-Enrollment Form

IC Title:

1. MUSE Caregiver Enrollment Form 7.9.18_CLEAN

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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
Other-Enrollment Form			1. MUSE Caregiver Enrollment Form FINAL_1.17.2019.pdf		No		Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 31

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	434	434
Annual IC Time Burden (Hours)	35	35
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.