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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

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-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 %

table that charts list of burden
	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

table that charts IC Documents
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.