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

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

Information Collection (IC) Details

View Information Collection (IC)

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

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 %

	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

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