View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	30724 Q_Medicaid.gov_updated by Michelle July 14 2020	Agency IC Tracking Number:	30724 Q_Medicaid.gov_updated by Michelle July 14 2

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
Form and Instruction	30724 Q_Medicaid.gov_updated by Michelle July 14 2	30724 Q_Medicaid.gov_updated by Michelle July 14 2020	30724 Q_Medicaid.gov_updated by Michelle July 14 2020.xlsx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,382	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	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	1,382	0	1,382	0	0	0
Annual IC Time Burden (Hours)	174	0	174	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Foresee Survey Approval - 1090-0008 Generic Clearance Request Form CMS June 2020 with signature	Foresee Survey Approval - 1090-0008 Generic Clearance Request Form CMS June 2020 with signature.pdf	03/17/2022
1090-0008 Survey Mapping Document CMS June 2020	1090-0008 Survey Mapping Document CMS June 2020.docx	03/17/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.