Information Collection

Annual Report on Home and Community-based Services Waivers

IC 43654 under ICR 201505-0938-010 · OMB 0938-0272.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0272 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-372 Annual Report on Home and Community-based Services Waivers Form and Instruction
CMS-372 Annual Report on Home and Community Based Waivers Blank 372 Screenshots.doc Form and Instruction
3 - CMS 372(S) Modifications Crosswalk 120514.doc Crosswalk IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Annual Report on Home and Community-based Services Waivers	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 and Instruction	CMS-372	Annual Report on Home and Community Based Waivers	Blank 372 Screenshots.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 48	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	315	10	305
Annual IC Time Burden (Hours)	13,545	430	13,115
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	3 - CMS 372(S) Modifications Crosswalk 120514.doc	05/21/2015

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