Information Collection

Beneficiary Feedback (sec. 447.203(b)(4))

IC 197690 under ICR 201105-0938-005 · OMB 0938-1134.

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Information Collection (IC) Details

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IC Title:	Beneficiary Feedback (sec. 447.203(b)(4))	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 447.203(b)(4)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	6,450	6,450
Annual IC Cost Burden (Dollars)	0	0

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