Title V Survey

Estimating the Gap Between the Needs of Children and Health Coverage and Benefits Through Implementation of the Affordable Care Act

Documents and Forms

Document Name Document Type
Form 1 Title V Survey Form and Instruction
1 survey Title V Survey.docx Form and Instruction
5.a. Prenotification E-mail_mr.docx 5 IC Document
5.b. Cover E-mail_mr.docx 5 IC Document
5.e. Reminder Email_mr.docx 5 IC Document

Information Collection (IC) Details

IC Title:	Title V Survey	Agency IC Tracking Number:

Is this a Common Form? No		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	1	survey	Title V Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 52	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	52	52
Annual IC Time Burden (Hours)	1,872	1,872
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
5	5.a. Prenotification E-mail_mr.docx	07/31/2013
5	5.b. Cover E-mail_mr.docx	07/31/2013
5	5.e. Reminder Email_mr.docx	07/31/2013

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