Screening

Survey to Inform the Children's Health Insurance Program (CHIP) National Outreach & Education Campaign

Documents and Forms

Document Name Document Type
Form CMS-10318 Screening Form and Instruction
CMS-10318 CHIP Survey CMS-10318. CHIP Survey FINAL-508COMPL.pdf Form and Instruction
CMS-10318 CMS Chip Medicaid Survey Final 10_19_10 CMS Chip Medicaid Survey.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Screening	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

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-10318	CHIP Survey	CMS-10318. CHIP Survey FINAL-508COMPL.pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-10318	CMS 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: 3,700	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	3,700	3,700
Annual IC Time Burden (Hours)	308	308
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.