Information Collection

Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report

IC 7986 under ICR 201003-0938-002 · OMB 0938-0354.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0354 can be found here:

Documents and Forms

Document Name Document Type
CMS-416 Instructions 11-09.docx Instruction
CMS-416 Annual EPSDT Participation report CMS 416 Form 11-09.xlsx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-416 Instructions 11-09.docx		No	No	Paper Only
Form	CMS-416	Annual EPSDT Participation report	CMS 416 Form 11-09.xlsx		Yes	Yes	Fillable Fileable

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: 75 %

	Approved	Previously Approved
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	1,568	1,568
Annual IC Cost Burden (Dollars)	15,000	15,000

Documents for IC

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.