Information Collection

Usability testing of the Supplemental Nutrition Assistance Program addendum

IC 251000 under ICR 202008-0607-006 · OMB 0607-0978.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0607-0978 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Usability testing of the Supplemental Nutrition Assistance Program addendum	Form and Instruction
1 Food Supplement Program-Paper Application Indiana_enclos Food Supplement Program-Paper Application Indiana_enclosure 3.pdf	Form and Instruction
2 Food Supplement Program-Paper Application MA_enclosure 3 Food Supplement Program-Paper Application MA_enclosure 3.pdf	Form and Instruction
3 Food Supplement Program-Paper Application MD_enclosure 3 Food Supplement Program-Paper Application MD_enclosure 3.pdf	Form and Instruction
4 Food Supplement Program-Paper Application Oklahoma_enclo Food Supplement Program-Paper Application Oklahoma_enclosure 3.pdf	Form and Instruction
5 Food Supplement Program-Paper Application VA_enclosure 3 Food Supplement Program-Paper Application VA_enclosure 3.pdf	Form and Instruction
OMB letter_fns_addendum_01_03_22_clean.docx OMB Letter	IC Document
omb letter_fns_ORIGINAL request_enclosure 1.docx Original OMB Letter approved oct 18 2019	IC Document
protocol _enclosure 2.docx Protocol	IC Document
demographic questionnaire enclosure 4.docx Demographic Questionnaire	IC Document
Mobile devise use questionnaire_enclosure 5.docx Mobile devise use questionnaire	IC Document
Satisfaction questionnaire_enclosure 6.docx Satisfaction questionnaire	IC Document
FNS - Usability Test Plan 8.19.19_enclosure 8_OMB_elo.docx Usability Test Plan	IC Document
consent form_enclosure 9_clean.docx Consent form	IC Document
additional screener question enclosure 7_OMB_elo.docx Additional screener questions	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Usability testing of the Supplemental Nutrition Assistance Program addendum

Agency IC Tracking Number:

IC Status: New

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?	Electronic Capability
Form and Instruction	1	Food Supplement Program-Paper Application Indiana_enclosure 3	Food Supplement Program-Paper Application Indiana_enclosure 3.pdf	No	Fillable Fileable
Form and Instruction	2	Food Supplement Program-Paper Application MA_enclosure 3	Food Supplement Program-Paper Application MA_enclosure 3.pdf	No	Fillable Fileable
Form and Instruction	3	Food Supplement Program-Paper Application MD_enclosure 3	Food Supplement Program-Paper Application MD_enclosure 3.pdf	No	Fillable Fileable
Form and Instruction	4	Food Supplement Program-Paper Application Oklahoma_enclosure 3	Food Supplement Program-Paper Application Oklahoma_enclosure 3.pdf	No	Fillable Fileable
Form and Instruction	5	Food Supplement Program-Paper Application VA_enclosure 3	Food Supplement Program-Paper Application VA_enclosure 3.pdf	No	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
OMB Letter	OMB letter_fns_addendum_01_03_22_clean.docx	01/03/2022
Original OMB Letter approved oct 18 2019	omb letter_fns_ORIGINAL request_enclosure 1.docx	01/03/2022
Protocol	protocol _enclosure 2.docx	01/03/2022
Demographic Questionnaire	demographic questionnaire enclosure 4.docx	01/03/2022
Mobile devise use questionnaire	Mobile devise use questionnaire_enclosure 5.docx	01/03/2022
Satisfaction questionnaire	Satisfaction questionnaire_enclosure 6.docx	01/03/2022
Usability Test Plan	FNS - Usability Test Plan 8.19.19_enclosure 8_OMB_elo.docx	01/31/2022
Consent form	consent form_enclosure 9_clean.docx	01/03/2022
Additional screener questions	additional screener question enclosure 7_OMB_elo.docx	01/31/2022

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