CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grant (Cycle III) Semi-Annual Report Template (Revised GenIC #7)

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10398 (#7) CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grant (Cycle III) Semi-Annual Report Template (Revised GenIC #7) Form and Instruction
CMS-10398 (#7) Connecting Kids to Coverage Grant Semi-Annual Report Tem CHIPRA Cycle III reporting template Final.doc Form and Instruction
Copy of Crosswalk Cycle III.xlsx Crosswalk IC Document
CHIPRA Cycle III - Semi Annual Report Supporting Statement [rev 3-9-2014 by OSORA PRA].docx Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	CHIPRA Connecting Kids to Coverage Outreach and Enrollment Grant (Cycle III) Semi-Annual Report Template (Revised GenIC #7)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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-10398 (#7)	Connecting Kids to Coverage Grant Semi-Annual Report Template for Grantees	CHIPRA Cycle III reporting template Final.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2	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	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	4	0	0	0	0	0
Annual IC Time Burden (Hours)	80	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Copy of Crosswalk Cycle III.xlsx	03/09/2014
Supporting Statement	CHIPRA Cycle III - Semi Annual Report Supporting Statement [rev 3-9-2014 by OSORA PRA].docx	03/09/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.