Information Collection

30724 2021 Medicaid.gov Feedback Survey

IC 250369 under ICR 202204-1090-002 · OMB 1090-0008.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1090-0008 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 30724 30724 2021 Medicaid.gov Feedback Survey	Form and Instruction
30724 30724 2021 Medicaid.gov Feedback Survey 30724 2021 Medicaid.gov Feedback Survey.xlsx	Form and Instruction
30724 30724 2021 Medicaid.gov Feedback Survey 30724 2021 Medicaid.gov Feedback Survey.xlsx	Form and Instruction
1090-0008 Generic Clearance Request - Medicaid.gov Feedback survey Fall 2021_signed Jayne Hammen.pdf 1090-0008 Generic Clearance Request - Medicaid.gov Feedback survey Fall 2021_signed Jayne Hammen	IC Document
1090-0008 Generic Clearance Request - Medicaid.gov Feedback survey Fall 2021_signed Jayne Hammen.pdf 1090-0008 Generic Clearance Request - Medicaid.gov Feedback survey Fall 2021_signed Jayne Hammen	IC Document
1090-0008 Survey Mapping Doc Medicaid.gov Feedback survey.docx 1090-0008 Survey Mapping Doc Medicaid.gov Feedback survey	IC Document
1090-0008 Survey Mapping Doc Medicaid.gov Feedback survey.docx 1090-0008 Survey Mapping Doc Medicaid.gov Feedback survey	IC Document

IC Title:

30724 2021 Medicaid.gov Feedback Survey

Agency IC Tracking Number:

30724

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
Form and Instruction	30724	30724 2021 Medicaid.gov Feedback Survey	30724 2021 Medicaid.gov Feedback Survey.xlsx		Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	1,300	1,300
Annual IC Time Burden (Hours)	22	22
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
1090-0008 Generic Clearance Request - Medicaid.gov Feedback survey Fall 2021_signed Jayne Hammen	1090-0008 Generic Clearance Request - Medicaid.gov Feedback survey Fall 2021_signed Jayne Hammen.pdf	11/16/2021
1090-0008 Survey Mapping Doc Medicaid.gov Feedback survey	1090-0008 Survey Mapping Doc Medicaid.gov Feedback survey.docx	11/16/2021

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