Information Collection

Tribal Consultation State Plan Amendment Template (CMS-10293)

IC 193149 under ICR 201006-0938-001 · OMB 0938-1098.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1098 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10293 Tribal Consultation State Plan Amendment Template (CMS-10293) Form and Instruction
CMS-10293 State Plan Amendment Template for Trival Consultation Un Preprint 5006 4-28-10.docx Form and Instruction
CMS-10293.SHO Letter.doc CMS-10293 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Tribal Consultation State Plan Amendment Template (CMS-10293)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Form and Instruction	CMS-10293	State Plan Amendment Template for Trival Consultation Under Title XIX of the Social Security Act	Preprint 5006 4-28-10.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 37	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
Annual Number of Responses for this IC	37	37
Annual IC Time Burden (Hours)	37	37
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10293	CMS-10293.SHO Letter.doc	05/19/2010

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