30724 2021 Medicaid.gov Feedback Survey

E-Government Website Customer Satisfaction Surveys

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1090-0008 can be found here:

Documents and Forms

Document Name Document Type
Form 30724 30724 2021 Medicaid.gov Feedback Survey Form and Instruction
30724 30724 2021 Medicaid.gov Feedback Survey 30724 2021 Medicaid.gov Feedback Survey.xlsx Form and Instruction
1090-0008 Generic Clearance Request - Medicaid.gov Feedback survey Fall 2021_signed Jayne Hammen.pdf 1090-0008 Generic Clearance Request - Medicaid.gov Feedback survey Fall 2021_signed Jayne Hammen IC Document
1090-0008 Survey Mapping Doc Medicaid.gov Feedback survey.docx 1090-0008 Survey Mapping Doc Medicaid.gov Feedback survey IC Document

Information Collection (IC) Details

IC Title:	30724 2021 Medicaid.gov Feedback Survey	Agency IC Tracking Number:	30724

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	30724 2021 Medicaid.gov Feedback Survey	30724 2021 Medicaid.gov Feedback Survey.xlsx		Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,300	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,300	1,300
Annual IC Time Burden (Hours)	22	22
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
1090-0008 Generic Clearance Request - Medicaid.gov Feedback survey Fall 2021_signed Jayne Hammen	1090-0008 Generic Clearance Request - Medicaid.gov Feedback survey Fall 2021_signed Jayne Hammen.pdf	11/16/2021
1090-0008 Survey Mapping Doc Medicaid.gov Feedback survey	1090-0008 Survey Mapping Doc Medicaid.gov Feedback survey.docx	11/16/2021

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