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State Plan Certification Form And State Health Plan Budget
STATE PLAN CERTIFICATION FORM AND STATE HEALTH PLAN BUDGET
OMB: 0937-0009
IC ID: 112199
OMB.report
HHS/OASH
OMB 0937-0009
ICR 197608-0937-001
IC 112199
( )
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
STATE PLAN CERTIFICATION FORM AND STATE HEALTH PLAN BUDGET
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Migrated
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
5153-1
No
No
Form
5153-2
No
No
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
335
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
0 %
Approved
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
335
0
0
335
0
0
Annual IC Time Burden (Hours)
8,200
0
0
8,200
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.