Information Collection

CHIP State Plan Eligibility (ICR #17)

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CHIP_E_Forms_Bucket2_25JUN2013.zip	Other-CHIP Eligibility State Plan Te
CHIP_E_Forms_Bucket3_25JUN2013.zip	Other-CHIP Eligibility State Plan Te
CHIP_E_Forms_Bucket4__25JUN2013.zip	Other-CHIP Eligibility State Plan Te
E_Forms_Bucket1.zip	Other-CHIP Eligibility State Plan Te
CHIP Templates Supporting Statement OPTIMIZED.pdf CHIP Templates Supporting Statement OPTIMIZED	IC Document

IC Title:

CHIP State Plan Eligibility (ICR #17)

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	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

Documents for IC

table that charts IC Documents
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.