Information Collection

Beneficiary Survey – Enrollment Version

IC 273151 under ICR 202604-0970-012 · OMB 0970-0642.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Instrument 1 - Beneficiary Survey - Enrollment Version (Clean).docx	Other-Survey
Instrument 1 - Beneficiary Survey - Enrollment Version (Clean).docx	Other-Survey

IC Title:

Beneficiary Survey â Enrollment Version

Agency IC Tracking Number:

Is this a Common Form? No

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
Other-Survey					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: 13,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	4,500	4,500
Annual IC Time Burden (Hours)	750	750
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.

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