Information Collection

Bundle: #7 (CHIPRA Cycle III and IV), #39 (Learning Collaboratives), and #40 (BIPP Template; formerly, CMS-10411, OCN 0938-1145)

IC 216111 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 (#7) Bundle: #7 (CHIPRA Cycle III and IV), #39 (Learning Collaboratives), and #40 (BIPP Template; formerly, CMS-10411, OCN 0938-1145)	Form
39 2015 03 09 State selection memo to CMS.DOCX	Other-39 State Selection Memo
CMS-10398 (#7) CHIPRA Cycle III - Semi-Annual Report Template 7 CHIPRA Cycle III reporting template Final [rev 04-15-2015 by OSORA PRA].doc	Form
CMS-10398 (#7) CHIPRA Cycle IV - Semi-Annual Report Template 7 CHIPRA Cycle IV Template.docx	Form
CMS-10398 (#39) 39 Protocol for BHP States 39 Year 4 MCFLO protocol for BHP states to CMS.DOCX	Form
CMS-10398 (#39) 39 Protocol for Coverave States 39 Year 4 MCFLO protocol for Coverage states to CMS.DOCX	Form
CMS-10398 (#39) 39 Protocol for DA States 39 Year 4 MCFLO protocol for DA states to CMS.DOCX	Form
CMS-10398 (#39) 39 Protocol for EI States 39 Year 4 MCFLO protocol for EI states to CMS.DOCX	Form
CMS-10398 (#39) 39 Protocol for FFM States 39 Year 4 MCFLO protocol for FFM states to CMS.DOCX	Form
CMS-10398 (#40) 40 Sample Balancing Incentive Report 40 Sample Balancing Incentive Report.pdf	Form
7 Supporting Statement [rev 04-15-2015].docx #7 Supporting Statement	IC Document
39 Supporting Statement [rev 04-14-2015 by OSORA PRA].docx 39 Supporting Statement	IC Document
40 Supporting Statement [rev 04-15-2015].docx 40 Supporting Statement	IC Document
Bundled Burden Table (04-15-2015 submission).xlsx Bundled GenIC Burden Table	IC Document

IC Title:

Bundle: #7 (CHIPRA Cycle III and IV), #39 (Learning Collaboratives), and #40 (BIPP Template; formerly, CMS-10411, OCN 0938-1145)

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398 (#7)	CHIPRA Cycle III - Semi-Annual Report Template	7 CHIPRA Cycle III reporting template Final [rev 04-15-2015 by OSORA PRA].doc	Yes	Yes	Fillable Printable
Form	CMS-10398 (#7)	CHIPRA Cycle IV - Semi-Annual Report Template	7 CHIPRA Cycle IV Template.docx	Yes	Yes	Fillable Printable
Other-39 State Selection Memo			39 2015 03 09 State selection memo to CMS.DOCX	No		Paper Only
Form	CMS-10398 (#39)	39 Protocol for BHP States	39 Year 4 MCFLO protocol for BHP states to CMS.DOCX	Yes	Yes	Fillable Printable
Form	CMS-10398 (#39)	39 Protocol for Coverave States	39 Year 4 MCFLO protocol for Coverage states to CMS.DOCX	Yes	Yes	Fillable Printable
Form	CMS-10398 (#39)	39 Protocol for DA States	39 Year 4 MCFLO protocol for DA states to CMS.DOCX	Yes	Yes	Fillable Printable
Form	CMS-10398 (#39)	39 Protocol for EI States	39 Year 4 MCFLO protocol for EI states to CMS.DOCX	Yes	Yes	Fillable Printable
Form	CMS-10398 (#39)	39 Protocol for FFM States	39 Year 4 MCFLO protocol for FFM states to CMS.DOCX	Yes	Yes	Fillable Printable
Form	CMS-10398 (#40)	40 Sample Balancing Incentive Report	40 Sample Balancing Incentive Report.pdf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	127	127
Annual IC Time Burden (Hours)	1,867	1,867
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#7 Supporting Statement	7 Supporting Statement [rev 04-15-2015].docx	04/15/2015
39 Supporting Statement	39 Supporting Statement [rev 04-14-2015 by OSORA PRA].docx	04/15/2015
40 Supporting Statement	40 Supporting Statement [rev 04-15-2015].docx	04/15/2015
Bundled GenIC Burden Table	Bundled Burden Table (04-15-2015 submission).xlsx	04/15/2015

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