State and Local Agencies

Healthy Incentives Pilot Evaluation

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0584-0561 can be found here:

Documents and Forms

Document Name Document Type
Appendix F1.docm Other-Round 1 Massachusetts Executiv
Appendix F2.docm Other-Round 2 Massachusetts Executiv
Appendix F3.docm Other-Round 3 Massachusetts Executiv
Appendix F4.docm Other-Round 1 DTA Staff HIP Intervie
Appendix F5.docm Other-Round 2 DTA Staff HIP Intervie
Appendix F6.docm Other-Round 3 DTA Staff HIP Intervie
Appendix F7.docm Other-Round 1 DTA Technical Team HIP
Appendix F8.docm Other-Round 2 DTA Technical Team HIP
Appendix F9.docm Other-Round 3 DTA Technical Team HIP
Appendix F10.docm Other-Round 1 Local Office Interview
Appendix F11.docm Other-Round 2 Local Office Interview
Appendix F12.docm Other-Round 3 Local Office Interview

Information Collection (IC) Details

IC Title:	State and Local Agencies	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-Round 1 Massachusetts Executive Interview Guide	Appendix F1.docm	No	Paper Only
Other-Round 2 Massachusetts Executive Interview Guide	Appendix F2.docm	No	Paper Only
Other-Round 3 Massachusetts Executive Interview Guide	Appendix F3.docm	No	Paper Only
Other-Round 1 DTA Staff HIP Interview Guide	Appendix F4.docm	No	Paper Only
Other-Round 2 DTA Staff HIP Interview Guide	Appendix F5.docm	No	Paper Only
Other-Round 3 DTA Staff HIP Interview Guide	Appendix F6.docm	No	Paper Only
Other-Round 1 DTA Technical Team HIP Interview Guide	Appendix F7.docm	No	Paper Only
Other-Round 2 DTA Technical Team HIP Interview Guide	Appendix F8.docm	No	Paper Only
Other-Round 3 DTA Technical Team HIP Interview Guide	Appendix F9.docm	No	Paper Only
Other-Round 1 Local Office Interview Guide	Appendix F10.docm	No	Paper Only
Other-Round 2 Local Office Interview Guide	Appendix F11.docm	No	Paper Only
Other-Round 3 Local Office Interview Guide	Appendix F12.docm	No	Paper Only

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 17	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	17	17
Annual IC Time Burden (Hours)	24	24
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.