Information Collection

#7: CHIPRA Cycle II Outreach and Enrollment Grant

IC 214286 under ICR 201410-0938-016 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10398 (# 7) #7: CHIPRA Cycle II Outreach and Enrollment Grant Form and Instruction
CMS-10398 (# 7) CHIPRA Cycle II Outreach and Enrollment Grant Semi-Annua CHIPRA Cycle II Semi-Annual Template_Final Draft for PRA [rev 04-11-2012 OSORA].doc Form and Instruction
#7 CHIPRA Cycle II - Semi Annual Report Supporting Statement [Dec 2014].docx #7 Supporting Statement: CHIPRA Cycle II Outreach and Enrollment Grant IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	#7: CHIPRA Cycle II Outreach and Enrollment Grant	Agency IC Tracking Number:

IC Status: New

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 and Instruction	CMS-10398 (# 7)	CHIPRA Cycle II Outreach and Enrollment Grant Semi-Annual Report	CHIPRA Cycle II Semi-Annual Template_Final Draft for PRA [rev 04-11-2012 OSORA].doc		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 39	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	78	78
Annual IC Time Burden (Hours)	1,560	1,560
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
#7 Supporting Statement: CHIPRA Cycle II Outreach and Enrollment Grant	#7 CHIPRA Cycle II - Semi Annual Report Supporting Statement [Dec 2014].docx	12/22/2014

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