Office of Community Care – IVC Survey Collection

Clearance for A-11 Section 280 Improving Customer Experience Information Collection

OMB: 2900-0876

IC ID: 273946

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
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Office of Community Care – IVC Survey Collection
 
Unchanged
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 2900-0876 Attending Wireframe Attending Community Care Wireframe 20250129.docx Yes Yes Fillable Fileable
Form and Instruction 2900-0876 Billing Wireframe Billing Community Care Wireframe 20250129.docx Yes Yes Fillable Fileable
Form and Instruction 2900-0876 Choosing Wireframe Choosing Community Care Wireframe 20250129.docx Yes Yes Fillable Fileable
Form and Instruction 2900-0876 Emergency Wireframe Emergency Community Care Wireframe 20250129.docx Yes Yes Fillable Fileable
Form and Instruction 2900-0876 RX Wireframe Prescription Community Care Wireframe 20250129.docx Yes Yes Fillable Fileable
Form and Instruction 2900-0876 Scheduling Wireframe Scheduling Community Care Wireframe 20250129.docx Yes Yes Fillable Fileable

Health Health Care Services

 

65,000 0
   
Individuals or Households
 
   100 %

  Requested 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 65,000 0 0 0 0 65,000
Annual IC Time Burden (Hours) 4,875 0 0 0 0 4,875
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
A-11 Template IVC Surveys A11 Fast-Track Clarance Request Template_OCC_IVC_Surveys.docx 02/27/2025
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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