OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

CHIP State Plan Eligibility (ICR #17)

IC 207567 under ICR 201111-0938-009 · OMB 0938-1148.

Documents and Forms
Document Name
Document Type
Other-CHIP Eligibility State Plan Te
Other-CHIP Eligibility State Plan Te
Other-CHIP Eligibility State Plan Te
Other-CHIP Eligibility State Plan Te
IC Document
Information Collection (IC) Details

View Information Collection (IC)

CHIP State Plan Eligibility (ICR #17)
 
New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-CHIP Eligibility State Plan Templates CHIP_E_Forms_Bucket2_25JUN2013.zip Yes Yes Fillable Printable
Other-CHIP Eligibility State Plan Templates CHIP_E_Forms_Bucket3_25JUN2013.zip Yes Yes Fillable Printable
Other-CHIP Eligibility State Plan Templates CHIP_E_Forms_Bucket4__25JUN2013.zip Yes Yes Fillable Printable
Other-CHIP Eligibility State Plan Templates E_Forms_Bucket1.zip Yes Yes Fillable Printable

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 56 0 0 0 0 0
Annual IC Time Burden (Hours) 2,800 0 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
CHIP Templates Supporting Statement OPTIMIZED CHIP Templates Supporting Statement OPTIMIZED.pdf 06/25/2013
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.