Information Collection

Tribal Consultation State Plan Amendment Template (CMS-10293)

IC 193149 under ICR 201307-0938-027 · OMB 0938-1098.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10293 Tribal Consultation State Plan Amendment Template (CMS-10293)	Form and Instruction
CMS-10293 State Plan Amendment Template for Trival Consultation Un Preprint 5006 4-28-10.docx	Form and Instruction
CMS-10293.SHO Letter.doc CMS-10293	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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-10293	State Plan Amendment Template for Trival Consultation Under Title XIX of the Social Security Act	Preprint 5006 4-28-10.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 37

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	Previously Approved
Annual Number of Responses for this IC	37	37
Annual IC Time Burden (Hours)	37	37
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10293	CMS-10293.SHO Letter.doc	05/19/2010

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