Information Collection

SSO Report of State Buy-in Problems

IC 221460 under ICR 201605-0938-009 · OMB 0938-0035.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0035 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-1957 SSO Report of State Buy-in Problems	Form
CMS-1957 State Buy-in Reports CMS-1957-508 (2015).pdf	Form

IC Title:

SSO Report of State Buy-in Problems

Agency IC Tracking Number:

CMS-1957

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 407.40

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-1957	State Buy-in Reports	CMS-1957-508 (2015).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,936

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	3,936	3,936
Annual IC Time Burden (Hours)	1,312	1,312
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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