Information Collection

Waiver Application

IC 195248 under ICR 201012-0938-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10361 Waiver Application	Form and Instruction
CMS-10361 CMS.10361.Deliberative Document CMS-10361.Deliberative Document.docx	Form and Instruction

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(a) 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

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-10361	CMS.10361.Deliberative Document	CMS-10361.Deliberative Document.docx		Yes	No	Fillable Fileable

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 %

table that charts list of burden
	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

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.