Information Collection

Transmittal and Notice of Approval of State Plan Material and Supporting Regulations in 42 CFR 430.10-430.20 and 440.167

IC 7877 under ICR 200707-0938-007 · OMB 0938-0193.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0193 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-179 Transmittal and Notice of Approval of State Plan Material and Supporting Regulations in 42 CFR 430.10-430.20 and 440.167	Form and Instruction
CMS-179 Transmittal Notice of Approval of State Plan Material cms179.pdf	Form and Instruction

IC Title:

Transmittal and Notice of Approval of State Plan Material and Supporting Regulations in 42 CFR 430.10-430.20 and 440.167

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 440.167 42 CFR 430.10 42 CFR 430.20

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-179	Transmittal Notice of Approval of State Plan Material	cms179.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 10 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	56	0	56
Annual IC Time Burden (Hours)	560	0	560
Annual IC Cost Burden (Dollars)	840	840	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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