View Information Collection (IC)

View Information Collection (IC)

IC Title:	GenIC #34 (Extension w/o change): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the SSA, State CHIP	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398 #34	Title XXI State Plan Template	34 - Title-XXI-State-Plan.docx		Yes	Yes	Fillable Fileable

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: 40	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	40	0	40	0	0	0
Annual IC Time Burden (Hours)	3,200	0	3,200	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
#34 - Supporting Statement	34 - Supporting Statement Model Application Template and Instructions for State Child Health Plan.docx	01/09/2018

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