Information Collection

Model Application Template for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program, & Model Application Template & Instructions

IC 8347 under ICR 201209-0938-006 · OMB 0938-0707.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-211 Model Application Template for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program, & Model Application Template & Instructions	Form and Instruction
CMS-R-211 Template for Child Health Plan Under Title XXI of the So Title XXI State Plan revised PRA 9-19-12.docx	Form and Instruction
Crosswalk of nonsub template changes for CMS-R-211.doc CMS-R-211 - Crosswalk (nonsubstantial changes)	IC Document

Information Collection (IC) Details

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IC Title:

Model Application Template for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program, & Model Application Template & Instructions

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 457.60

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-R-211	Template for Child Health Plan Under Title XXI of the Social Security Act Children's Health Insurance Program	Title XXI State Plan revised PRA 9-19-12.docx		Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54

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
	Approved	Previously Approved
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	3,200	3,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-R-211 - Crosswalk (nonsubstantial changes)	Crosswalk of nonsub template changes for CMS-R-211.doc	09/23/2012

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