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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
GenIC #1 - Initial Application
Agency IC Tracking Number:
IC Status:
New
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CMS-10434 (#1)
Initial Application
GenIC #1 Screen Shots - Initial Application.pdf
Yes
Yes
Fillable Printable
Form
CMS-10434 (#1)
Initial Application (SPA Administration)
GenIC #1 Screen Shots - SPA Admin.pdf
Yes
Yes
Fillable Printable
Form
CMS-10434 (#1)
MACPro Homepage
GenIC #1 - MACPro Home Page.jpg
Yes
Yes
Fillable Printable
Instruction
#1 - IG_A1-Designation and Authority_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#1 - IC_A2-Organization and Administration_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#1 - IG_A3-Assurances_R1_Final_11-30-12.docx
No
Printable Only
Instruction
#1 - IG_I1_State Information_R1_Draft_11-30-12.docx
No
Printable Only
Instruction
#1 - IG_I2 - Medicaid State Plan-Specific Submission Data_R1_Draft_11-30-12.docx
No
Printable Only
Instruction
#1 - IG_I4 - CHIP Amendment Submission_R1 Final_11-30-12.docx
No
Printable Only
Instruction
#1 - IG_I5 - Public Comment_R1_Draft_11-30-12.docx
No
Printable Only
Instruction
#1 - IG_I6 - Tribal Input_R1_Draft_11-30-12.docx
No
Printable Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
56
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
100 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
56
0
56
0
0
0
Annual IC Time Burden (Hours)
476
0
476
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
GenIC #1 - Supporting Statement (Initial Application)
GenIC # 1 - Supporting Statement Initial Application Templates [rev 03-28-2016 by OSORA PRA].docx
03/30/2016
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.