Information Collection

Dental Action Plan Template for Medicaid and CHIP Programs

IC 200696 under ICR 201201-0938-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10368 Dental Action Plan Template for Medicaid and CHIP Programs	Form and Instruction
CMS-10368 Dental Action Plan Template for Medicaid and CHIP Progra 508ed_12-8 Dental Template for SHO PRA Comments.pdf	Form and Instruction
Crosswalk 12-16-11.docx Crosswalk (changes from 60- to 30-day notices)	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10368	Dental Action Plan Template for Medicaid and CHIP Programs	508ed_12-8 Dental Template for SHO PRA Comments.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 69

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
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	69	69
Annual IC Time Burden (Hours)	4,485	4,485
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk (changes from 60- to 30-day notices)	Crosswalk 12-16-11.docx	12/27/2011

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