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Federal forms, ICRs, and supporting documents

Information Collection

Background and Demographic Information Form

IC 195559 under ICR 202503-0915-001 · OMB 0915-0338.

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

View Information Collection (IC)

Background and Demographic Information Form
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 2 Background Form B1 - Background Form.docx Yes Yes Fillable Fileable
Form and Instruction 1 Demographic Form 0915-0338_MCHB_HSMED_Demographic_Form_Redline_03052025.docx Yes Yes Fillable Fileable

Health Health Care Services

 

45,450 0
   
Individuals or Households
 
   75 %

  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 45,450 0 0 0 0 45,450
Annual IC Time Burden (Hours) 27,270 0 0 0 0 27,270
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.