View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

OMB Control No: 0938-0988	ICR Reference No: 202002-0938-008
Status: Historical Active	Previous ICR Reference No: 201612-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: OFM
Title: State Children's Health Insurance Program (SCHIP) Report on Payables and Receivables (CMS-10180)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/23/2020
	Date Received in OIRA: 02/26/2020
Terms of Clearance: Prior to use, the OMB control number and expiration date must be added to the online form. In addition, in any future revision, extension, or re-instatement request for this collection, CMS shall give reasonable notice to respondents of 1. Whether responses to the collection of information are voluntary, required to obtain or retain a benefit (citing authority), or mandatory (citing authority) and 2. The nature and extent of confidentiality to be provided, if any (citing authority) (see 5 CFR 1320.8(b)(3)). This notice shall be provided in the manner prescribed by 5 CFR 1320.8(c)(1).

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2023	36 Months From Approved	06/30/2020
Responses	56	0	56
Time Burden (Hours)	1,792	0	392
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	56	56	0
Annual Time Burden (Hours)	1,792	392	1,400
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The change in burden is due to an increased estimate in the time to complete the form, which resulted in the total burden hours increasing from 392 hours to 1,792 hours.

Annual Cost to Federal Government: $5,389

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Stephan McKenzie 410 786-1943 stephan.mckenzie@cms.hhs.gov

Something went wrong when downloading this file. If you have any questions, please send an email to risc@gsa.gov.