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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
GenIC #57 (Revision): Medicaid Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates
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
Instruction
SUD_MonProtocolInstr.v4.0_PRA.pdf
Yes
Yes
Printable Only
Form
CMS-10398 #57
Monitoring Protocol Template
SUD_MonProtocolTemp.v4.0_PRA.docx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #57
Monitoring Protocol Workbook
SUD_MonProtocolWB.v6.0_PRA.xlsx
Yes
Yes
Fillable Fileable
Instruction
SUD_MonReportInstr.v4.0_PRA.pdf
Yes
Yes
Printable Only
Form
CMS-10398 #57
Monitoring Report Template
SUD_MonReportTemp.v4.0_PRA.docx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #57
Monitoring Report Workbook
SUD_MonReportWB.v6.0_PRA.xlsx
Yes
Yes
Fillable Fileable
Instruction
Video - Downloading 1115 Demonstration Monitoring Report Templates.docx
https://cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/
Yes
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:
35
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
596
0
0
0
0
596
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
57 - Generic Supporting Statement (2022 version 6).docx
03/15/2022
Crosswalk: Monitoring Protocol Instructions
SUD Crosswalk 2022_Monitoring Protocol Instructions.xlsx
03/15/2022
Crosswalk: Monitoring Protocol Template
SUD Crosswalk 2022_Monitoring Protocol Template.xlsx
03/15/2022
Crosswalk: Monitoring Protocol Workbook
SUD Crosswalk 2022_Monitoring Protocol Workbook.xlsx
03/15/2022
Crosswalk: Monitoring Report Instructions
SUD Crosswalk 2022_Monitoring Report Instructions.xlsx
03/15/2022
Crosswalk: Monitoring Report Template
SUD Crosswalk 2022_Monitoring Report Template.xlsx
03/15/2022
Crosswalk: Monitoring Report Workbook
SUD Crosswalk 2022_Monitoring Report Workbook.xlsx
03/15/2022
SMDL #17-003
SMDL 17-003.pdf
03/15/2022
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.