Information Collection

30724 Q_Medicaid.gov_updated by Michelle July 14 2020

IC 252231 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⚠️ Notice: This information collection may be referencing outdated material.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 Q_Medicaid.g 30724 Q_Medicaid.gov_updated by Michelle July 14 2020	Form and Instruction
30724 Q_Medicaid.g 30724 Q_Medicaid.gov_updated by Michelle July 14 2020 30724 Q_Medicaid.gov_updated by Michelle July 14 2020.xlsx	Form and Instruction
30724 Q_Medicaid.g 30724 Q_Medicaid.gov_updated by Michelle July 14 2020 30724 Q_Medicaid.gov_updated by Michelle July 14 2020.xlsx	Form and Instruction
Foresee Survey Approval - 1090-0008 Generic Clearance Request Form CMS June 2020 with signature.pdf Foresee Survey Approval - 1090-0008 Generic Clearance Request Form CMS June 2020 with signature	IC Document
Foresee Survey Approval - 1090-0008 Generic Clearance Request Form CMS June 2020 with signature.pdf Foresee Survey Approval - 1090-0008 Generic Clearance Request Form CMS June 2020 with signature	IC Document
1090-0008 Survey Mapping Document CMS June 2020.docx 1090-0008 Survey Mapping Document CMS June 2020	IC Document
1090-0008 Survey Mapping Document CMS June 2020.docx 1090-0008 Survey Mapping Document CMS June 2020	IC Document

IC Title:

30724 Q_Medicaid.gov_updated by Michelle July 14 2020

Agency IC Tracking Number:

30724 Q_Medicaid.gov_updated by Michelle July 14 2

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 Q_Medicaid.gov_updated by Michelle July 14 2	30724 Q_Medicaid.gov_updated by Michelle July 14 2020	30724 Q_Medicaid.gov_updated by Michelle July 14 2020.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: 1,382

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	1,382	1,382
Annual IC Time Burden (Hours)	174	174
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Foresee Survey Approval - 1090-0008 Generic Clearance Request Form CMS June 2020 with signature	Foresee Survey Approval - 1090-0008 Generic Clearance Request Form CMS June 2020 with signature.pdf	03/17/2022
1090-0008 Survey Mapping Document CMS June 2020	1090-0008 Survey Mapping Document CMS June 2020.docx	03/17/2022

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