Information Collection

State Plan Pre-print implementing Section 6087 of the DRA: Optional Self-Direction PAS Program (Cash and Counseling) CMS-10234

IC 181537 under ICR 201005-0938-003 · OMB 0938-1024.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10234 State Plan Pre-print implementing Section 6087 of the DRA: Optional Self-Direction PAS Program (Cash and Counseling) CMS-10234	Form
CMS-10234 SMD Letter Self Direction.doc	Instruction
CMS-10234 1915(j) Self-Directed PAS State Plan Amendment Preprint spapreprint 5 4 07 PRA version DEC09.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 1396

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	CMS-10234	1915(j) Self-Directed PAS State Plan Amendment Preprint	spapreprint 5 4 07 PRA version DEC09.docx		No	No	Fillable Printable
Instruction			CMS-10234 SMD Letter Self Direction.doc		No	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	20	-36	56
Annual IC Time Burden (Hours)	400	-720	1,120
Annual IC Cost Burden (Dollars)	0	0	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.