Information Collection

1932 State Plan Amendment Template

IC 8781 under ICR 201704-0938-005 · OMB 0938-0933.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10120 1932 State Plan Amendment Template 1932 State Plan Amendment Template	Form
CMS-10120 1932 State Plan Amendment Template 1932a State Plan Preprint- 508 approved [rev 04-21-2017 by OSORA PRA].pdf	Form
Crosswalk 1932a - 508 approved.pdf Crosswalk	IC Document

IC Title:

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:

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-10120				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	12	-3	15
Annual IC Time Burden (Hours)	70	-15	85
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk		04/21/2017

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

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