Information Collection

Phase 1 Enrollment Survey A

IC 218918 under ICR 202103-0920-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Phase 1 Enrollment Survey A Form and Instruction
Phase 1 Enrollment Survey A (English) Att 6a_Phase 1 Enrollment Survey A (English).docx Form and Instruction
Phase 1 Enrollment Survey A (English) Att 6a_Phase 1 Enrollment Survey A (English).docx Form and Instruction
Phase 1 Enrollment Survey A (Spanish) Att 6b_Phase 1 Enrollment Survey A (Spanish).docx Form and Instruction
Phase 1 Enrollment Survey A (Spanish) Att 6b_Phase 1 Enrollment Survey A (Spanish).docx Form and Instruction
Phase 1 Enrollment Survey A (screen shots) Att 12a_Screenshots_Phase 1 Enrollment Survey A.pdf Form and Instruction
Phase 1 Enrollment Survey A (screen shots) Att 12a_Screenshots_Phase 1 Enrollment Survey A.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Phase 1 Enrollment Survey A	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 A (English)	Att 6a_Phase 1 Enrollment Survey A (English).docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Phase 1 Enrollment Survey A (Spanish)	Att 6b_Phase 1 Enrollment Survey A (Spanish).docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Phase 1 Enrollment Survey A (screen shots)	Att 12a_Screenshots_Phase 1 Enrollment Survey A.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,667	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-1,667	1,667
Annual IC Time Burden (Hours)	-1,250	1,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.