View Information Collection (IC)

View Information Collection (IC)

IC Title:	State Agency Contact Form (CMS-368)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-368	State Agency Contact Form	CMS-368 State Agency Contact Form_10.2021_Fillable_Final.pdf		Yes	Yes	Fillable Printable

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: 10	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	10	0	0	0	0	10
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
Crosswalk: Contact Form	CMS-368 State Agency Contact Form_Crosswalk_10.2021.pdf	02/17/2022

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