Information Collection

HH Demo for Mailed Requests (16 States)

IC 222825 under ICR 202611-0938-005 · OMB 0938-1311.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

HH Demo for Mailed Requests (16 States)

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
Instruction					Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,700

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	634,603	634,603
Annual IC Time Burden (Hours)	317,301	317,301
Annual IC Cost Burden (Dollars)	17,223,132	17,223,132

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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