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ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
GenIC #34 (Revised): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program
Agency IC Tracking Number:
CMCS
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 and Instruction
CMS-10398 #34
Template for Child Health Plan Under Title XXI of the Social Security Act Children’s Health Insurance Program
10.23.19_title-xxi-state-plan-template_508_BH updates_clean.docx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #34
Crosswalk - Template
Copy of Crosswalk Behavioral Health State Plan Update PRA_5.31.19.xlsx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #34
Track Changes - Template
10.23.19_title-xxi-state-plan-template_508_BH updates_track changes.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:
41
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 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
1
0
1
0
0
0
Annual IC Time Burden (Hours)
75
0
75
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
GenIC #34 - Generic Supporting Statement
#34 - Generic Supporting Statement (2019 version 2c).docx
11/07/2019
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.