View Information Collection (IC)

View Information Collection (IC)

IC Title:	GenIC #72 (Nonsubstantive Change): Expressions of Interest in the Infant Well-Child Visit Affinity Group	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	CMS-10398 #72	Expression of Interest Form	well-child-visit-ag-interest-form.pdf		Yes	Yes	Fillable Fileable
Other-Affinity Group Fact Sheet			well-child-visit-ag-fact-sheet.pdf		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: 20	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	20	0	20	0	0	0
Annual IC Time Burden (Hours)	5	0	5	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Generic Supporting Statement	GenIC 72 - Generic Supporting Statement (2021 version 7).docx	08/27/2021
Justification for Nonsubstantive Change	Justification for Nonsubstantive Change.docx	08/27/2021

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