Information Collection

Phase 1 Enrollment Survey

IC 218945 under ICR 202112-0920-002 · OMB 0920-1100.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1100 Phase 1 Enrollment Survey	Form and Instruction
Form 0920-1100 Att 7a_Phase 1 Enrollment Survey (English) Phase 1 Enrollment Survey	Form and Instruction
Form 0920-1100 Att 7b_Phase 1 Enrollment Survey (Spanish) Phase 1 Enrollment Survey	Form and Instruction
Att 12a_Screenshots_REDCaP_Phase 1 Enrollment Survey.pdf	Other-Screenshot
Att 12a_Screenshots_REDCaP_Phase 1 Enrollment Survey.pdf	Other-Screenshot
0920-1100 Att 7a_Phase 1 Enrollment Survey (English) Prt2 Wrksht_att 7_Phase 1 Enrollment Survey.pdf	Form and Instruction
0920-1100 Att 7a_Phase 1 Enrollment Survey (English) Prt2 Wrksht_att 7_Phase 1 Enrollment Survey.pdf	Form and Instruction
0920-1100 Att 7b_Phase 1 Enrollment Survey (Spanish) Att 7b_Phase 1 Enrollment Survey (Spanish).docx	Form and Instruction
0920-1100 Att 7b_Phase 1 Enrollment Survey (Spanish) Att 7b_Phase 1 Enrollment Survey (Spanish).docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-1100

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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-1100	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1100	Yes	Yes	Fillable Fileable
Other-Screenshot		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,867

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	1,867	1,867
Annual IC Time Burden (Hours)	934	934
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].