OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Phase 1 Enrollment Survey

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

Documents and Forms
Document Name
Document Type
Form and Instruction
Other-Screenshot
Other-Screenshot
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Phase 1 Enrollment Survey 0920-1100
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 0920-1100 Att 7a_Phase 1 Enrollment Survey (English) Prt2 Wrksht_att 7_Phase 1 Enrollment Survey.pdf Yes Yes Fillable Fileable
Form and Instruction 0920-1100 Att 7b_Phase 1 Enrollment Survey (Spanish) Att 7b_Phase 1 Enrollment Survey (Spanish).docx Yes Yes Fillable Fileable
Other-Screenshot Att 12a_Screenshots_REDCaP_Phase 1 Enrollment Survey.pdf Yes Yes Printable Only

Health Health Care Services

 

1,867 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,867 0 0 0 0 1,867
Annual IC Time Burden (Hours) 934 0 0 0 0 934
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.