Information Collection

1932 State Plan Amendment Template, State Plan Requirements, and Supporting Regulations in 42 CFR 438.50

IC 8781 under ICR 201402-0938-014 · OMB 0938-0933.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0933 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10120 1932 State Plan Amendment Template, State Plan Requirements, and Supporting Regulations in 42 CFR 438.50 Form
CMS-10120 1932a SPA Preprint Official 1932 State Plan Preprint (2014 draft) -clean for PRA 10_18 10-30.pdf Form
Crosswalk of changes to 1932 SPA Preprint_final 508 approved.docx Crosswalk IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	1932 State Plan Amendment Template, State Plan Requirements, and Supporting Regulations in 42 CFR 438.50	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10120	1932a SPA Preprint	Official 1932 State Plan Preprint (2014 draft) -clean for PRA 10_18 10-30.pdf		Yes	Yes	Fillable Printable

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 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	15	5	10
Annual IC Time Burden (Hours)	85	-15	100
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Crosswalk of changes to 1932 SPA Preprint_final 508 approved.docx	02/25/2014

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