Information Collection

Initial Application

IC 205309 under ICR 201301-0938-004 · OMB 0938-1188.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1188 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
IG_I1_State Information_R1_Draft_11-30-12.docx	Instruction
IG_I4 - CHIP Amendment Submission_R1 Final_11-30-12.docx	Instruction
IG_I2 - Medicaid State Plan-Specific Submission Data_R1_Draft_11-30-12.docx	Instruction
IG_I5 - Public Comment_R1_Draft_11-30-12.docx	Instruction
IG_I6 - Tribal Input_R1_Draft_11-30-12.docx	Instruction
CMS-10434 Initial Application Initial Application Form.pdf	Form and Instruction
Initial Application Transcript.pdf Initial Application - Webinar Transcript	IC Document

IC Title:

Initial Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 430.12

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
Instruction			IG_I1_State Information_R1_Draft_11-30-12.docx	Yes	No	Printable Only
Form and Instruction	CMS-10434	Initial Application	Initial Application Form.pdf	Yes	Yes	Fillable Fileable
Instruction			IG_I4 - CHIP Amendment Submission_R1 Final_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_I2 - Medicaid State Plan-Specific Submission Data_R1_Draft_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_I5 - Public Comment_R1_Draft_11-30-12.docx	Yes	No	Printable Only
Instruction			IG_I6 - Tribal Input_R1_Draft_11-30-12.docx	Yes	No	Printable Only

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	280	280
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Initial Application - Webinar Transcript	Initial Application Transcript.pdf	01/08/2013

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