OMB.report

Federal forms, ICRs, and supporting documents

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.

Documents and Forms
Document Name
Document Type
Form
Other-39 State Selection Memo
Form
Form
Form
Form
Form
Form
Form
Form
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

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

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

35 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 127 0 127 0 0 0
Annual IC Time Burden (Hours) 1,867 0 1,867 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.