Information Collection

Section 1115 Demonstration Application Template

IC 200533 under ICR 201112-0938-009 · OMB 0938-1159.

Documents and Forms

Document Name Document Type
Form CMS-10412 Section 1115 Demonstration Application Template Form and Instruction
CMS-10412 Section 1115 Demonstration Application Template Section 1115 Application Template [rev 12-15-11].docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Section 1115 Demonstration Application Template	Agency IC Tracking Number:

Is this a Common Form? No		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-10412	Section 1115 Demonstration Application Template	Section 1115 Application Template [rev 12-15-11].docx		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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	11	11
Annual IC Time Burden (Hours)	448	448
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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