State official responsible for administering the Medicaid Program

Homelessness Data for Health and Human Services Mainstream Programs

Documents and Forms

Document Name Document Type
0990-Homelessness Data - Survey 1 (Medicaid - do include) 8-9-2007.doc Other-Medicaid Survey
0990-Homelessness Data - Survey 2 (Medicaid - do not include) 8-9-2007.doc Other-Medicaid Survey

Information Collection (IC) Details

IC Title:	State official responsible for administering the Medicaid Program	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Medicaid Survey			0990-Homelessness Data - Survey 1 (Medicaid - do include) 8-9-2007.doc		No	No	Paper Only
Other-Medicaid Survey			0990-Homelessness Data - Survey 2 (Medicaid - do not include) 8-9-2007.doc		No	No	Paper Only

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	51	51
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.