Information Collection

Waiver Application

IC 195248 under ICR 201011-0938-008 · OMB 0938-1114.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1114 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Waiver Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 158.321(b) 45 CFR 158.321(c) 45 CFR 158.321(d)(1)-(13) 45 CFR 158.322 45 CFR 158.323 45 CFR 158.321(a)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

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	Program Change Due to New Statute
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	3,700	3,700
Annual IC Cost Burden (Dollars)	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.