Information Collection

Statewide HCBS Transition Plans (# 31)

IC 212183 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⚠️ Notice: This information collection may be referencing outdated material.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 (#31) Statewide HCBS Transition Plans (# 31)	Form
State Transition Plan for Compliance (2).docx	Instruction
Heightened Scrutiny in Transition Plan 5-14-2014.docx	Instruction
CMS-10398 (#31) Sample Template for State Settings’ Analysis Template for State Settings Analysis.docx	Form
Statewide HCBS Transistion Plan Spporting Statement [rev 7-2-2014 by OSORA PRA].docx Supporting Statement A	IC Document

IC Title:

Statewide HCBS Transition Plans (# 31)

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398 (#31)	Sample Template for State Settingsâ Analysis	Template for State Settings Analysis.docx	Yes	No	Fillable Printable
Instruction			State Transition Plan for Compliance (2).docx	Yes	No	Paper Only
Instruction			Heightened Scrutiny in Transition Plan 5-14-2014.docx	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 48

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 Agency Discretion
Annual Number of Responses for this IC	48	48
Annual IC Time Burden (Hours)	2,016	2,016
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	Statewide HCBS Transistion Plan Spporting Statement [rev 7-2-2014 by OSORA PRA].docx	07/02/2014

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