Information Collection

Survey

IC 194459 under ICR 201008-0938-021 · OMB 0938-1112.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10318 CHIP Survey Survey	Form and Instruction
Form CMS-10318CMS Chip CMS-10318CMS Chip Medicaid Survey Final 10_19_10 Survey	Form and Instruction
CMS-10318 CHIP Survey CMS-10318. CHIP Survey FINAL-508COMPL.pdf	Form and Instruction
CMS-10318CMS Chip CMS-10318CMS Chip Medicaid Survey Final 10_19_10 CMS Chip Medicaid Survey.pdf	Form and Instruction

IC Title:

Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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-10318	CHIP Survey	CMS-10318. CHIP Survey FINAL-508COMPL.pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-10318CMS Chip Medicaid Survey Final 10_19_10	CMS-10318CMS Chip Medicaid Survey Final 10_19_10	CMS Chip Medicaid Survey.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,850

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	1,850	1,850
Annual IC Time Burden (Hours)	925	925
Annual IC Cost Burden (Dollars)	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.