Information Collection

MAPCP - State Officials

IC 206743 under ICR 201304-0938-009 · OMB 0938-1211.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10436 MAPCP - State Officials	Form and Instruction
CMS-10436 Protocol - State Officials Protocol_State_2-14-13.pdf	Form and Instruction
CMS-10436 Protocol - DAAS care managers protocol_DAAS_care_mgrs_2-13-13.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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-10436	Protocol - State Officials	Protocol_State_2-14-13.pdf		No	No	Paper Only
Form and Instruction	CMS-10436	Protocol - DAAS care managers	protocol_DAAS_care_mgrs_2-13-13.pdf		No	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)	72	72
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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