Information Collection

Beneficiary Survey – Enrollment Version

IC 273151 under ICR 202604-0970-005 · OMB 0970-0642.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0642 can be found here:

Documents and Forms

Document Name Document Type
Instrument 1 - Beneficiary Survey - Enrollment Version (Clean).docx Other-Survey

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Survey			Instrument 1 - Beneficiary Survey - Enrollment Version (Clean).docx		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 %

	Requested	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

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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