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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.