Information Collection

State Children's Health Insurance Program and Supporting Regulations in 42 CFR 457.525, 457.740, and 457.1180

IC 8644 under ICR 201704-0938-012 · OMB 0938-0841.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0841 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-308 State Children's Health Insurance Program and Supporting Regulations in 42 CFR 457.525, 457.740, and 457.1180	Form
CMS-R-308 (Forms: SEDS SEDSInstructions.pdf	Form and Instruction
CMS-R-308 SEDS Report Complete SEDS Report_Example.pdf	Form

IC Title:

State Children's Health Insurance Program and Supporting Regulations in 42 CFR 457.525, 457.740, and 457.1180

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 457.350 42 CFR 457.1180 42 CFR 457.525 42 CFR 457.740

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-R-308	SEDS Report	Complete SEDS Report_Example.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-308 (Forms: 21E, 21PW, 64.21E, 64EC, and 21)	SEDS	SEDSInstructions.pdf		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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	9,537,276	-18,757,320	28,294,596
Annual IC Time Burden (Hours)	479,140	-994,715	1,473,855
Annual IC Cost Burden (Dollars)	0	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.