Information Collection

HIV/AIDS Bureau Core Medical Services Waiver

IC 181012 under ICR 201401-0915-001 · OMB 0915-0307.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0307 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form.Core Medical Services Waiver Application.docx	Instruction
CMSwaiver legislation-Parts A-B-C_RW ExtenAct2009.doc CMSwaiver legislation-Parts A-B-C_RW ExtenAct2009	IC Document

IC Title:

HIV/AIDS Bureau Core Medical Services Waiver

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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
Instruction			Form.Core Medical Services Waiver Application.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	20	10	10
Annual IC Time Burden (Hours)	110	45	65
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMSwaiver legislation-Parts A-B-C_RW ExtenAct2009	CMSwaiver legislation-Parts A-B-C_RW ExtenAct2009.doc	01/28/2014

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