Information Collection

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

IC 210670 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⚠️ Notice: This information collection may be referencing outdated material.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
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

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:

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-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 %

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	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

table that charts IC Documents
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.