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Agenda
Reg Review
ICR
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:
Unchanged
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 %
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
20
0
0
0
0
20
Annual IC Time Burden (Hours)
5
0
0
0
0
5
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.