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CHIP/Medicaid Enrollees and Disenrollees
CHIPRA_ Children Health Insurance
OMB: 0990-0384
IC ID: 199533
OMB.report
HHS/HHSDM
OMB 0990-0384
ICR 201110-0990-006
IC 199533
( )
Documents and Forms
Document Name
Document Type
0990-CHIP Part B_Attachment B1_CHIP Survey of Enrollees and Disenrollees.pdf
Other-survey
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
CHIP/Medicaid Enrollees and Disenrollees
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
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-survey
0990-CHIP Part B_Attachment B1_CHIP Survey of Enrollees and Disenrollees.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
19,500
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
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
19,500
0
19,500
0
0
0
Annual IC Time Burden (Hours)
9,750
0
9,750
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
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.
