Information Collection

State Medical Support Contacts and Program Requirement Matrix (State Respondents)

IC 255976 under ICR 202211-0970-008 · OMB 0970-0222.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0222 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NMSN Matrix State Medical Support Contacts and Program Requirement Matrix (State Respondents)	Form
Form NMSN Matrix State Medical Support Contacts and Program Requirement Matrix (State Respondents)	Form
NMSN Matrix State Medical Support Contacts and Program Requirement M 2022_10_27_NMSN_State_Medical_Support_Contacts_and_Program_Requirements_after 30 Day comments_clean.docx	Form
NMSN Matrix State Medical Support Contacts and Program Requirement M 2022_10_27_NMSN_State_Medical_Support_Contacts_and_Program_Requirements_after 30 Day comments_clean.docx	Form

IC Title:

State Medical Support Contacts and Program Requirement Matrix (State Respondents)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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	NMSN Matrix	State Medical Support Contacts and Program Requirement Matrix	2022_10_27_NMSN_State_Medical_Support_Contacts_and_Program_Requirements_after 30 Day comments_clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	54	54
Annual IC Time Burden (Hours)	54	54
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.