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OMB Control No: 0938-0354	ICR Reference No: 202604-0938-013
Status: Received in OIRA	Previous ICR Reference No: 202305-0938-017
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report (CMS-416)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 04/16/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	07/31/2026
Responses	56	56
Time Burden (Hours)	1,128	1,512
Cost Burden (Dollars)	0	0

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	56	56	0
Annual Time Burden (Hours)	1,128	1,512	-384
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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This 2026 collection of information request is a Revision that proposes changes to the CMS-416 form and the form’s instructions. We are also proposing to reduce our burden estimates by 384 hours and $25,834. See section 15 of the Supporting Statement for details.

Annual Cost to Federal Government: $139,525

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: Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov

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