Information Collection

GenIC #1 - Initial Application

IC 220807 under ICR 201708-0938-004 · OMB 0938-1188.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1188 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10434 (#1) GenIC #1 - Initial Application Form
#1 - IG_A1-Designation and Authority_R1_Final_11-30-12.docx Instruction
#1 - IC_A2-Organization and Administration_R1_Final_11-30-12.docx Instruction
#1 - IG_A3-Assurances_R1_Final_11-30-12.docx Instruction
#1 - IG_I1_State Information_R1_Draft_11-30-12.docx Instruction
#1 - IG_I2 - Medicaid State Plan-Specific Submission Data_R1_Draft_11-30-12.docx Instruction
#1 - IG_I4 - CHIP Amendment Submission_R1 Final_11-30-12.docx Instruction
#1 - IG_I5 - Public Comment_R1_Draft_11-30-12.docx Instruction
#1 - IG_I6 - Tribal Input_R1_Draft_11-30-12.docx Instruction
CMS-10434 (#1) Initial Application GenIC #1 Screen Shots - Initial Application.pdf Form
CMS-10434 (#1) Initial Application (SPA Administration) GenIC #1 Screen Shots - SPA Admin.pdf Form
CMS-10434 (#1) MACPro Homepage GenIC #1 - MACPro Home Page.jpg Form
GenIC # 1 - Supporting Statement Initial Application Templates [rev 03-28-2016 by OSORA PRA].docx GenIC #1 - Supporting Statement (Initial Application) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	GenIC #1 - Initial Application	Agency IC Tracking Number:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10434 (#1)	Initial Application	GenIC #1 Screen Shots - Initial Application.pdf	Yes	Yes	Fillable Printable
Form	CMS-10434 (#1)	Initial Application (SPA Administration)	GenIC #1 Screen Shots - SPA Admin.pdf	Yes	Yes	Fillable Printable
Form	CMS-10434 (#1)	MACPro Homepage	GenIC #1 - MACPro Home Page.jpg	Yes	Yes	Fillable Printable
Instruction			#1 - IG_A1-Designation and Authority_R1_Final_11-30-12.docx	No		Printable Only
Instruction			#1 - IC_A2-Organization and Administration_R1_Final_11-30-12.docx	No		Printable Only
Instruction			#1 - IG_A3-Assurances_R1_Final_11-30-12.docx	No		Printable Only
Instruction			#1 - IG_I1_State Information_R1_Draft_11-30-12.docx	No		Printable Only
Instruction			#1 - IG_I2 - Medicaid State Plan-Specific Submission Data_R1_Draft_11-30-12.docx	No		Printable Only
Instruction			#1 - IG_I4 - CHIP Amendment Submission_R1 Final_11-30-12.docx	No		Printable Only
Instruction			#1 - IG_I5 - Public Comment_R1_Draft_11-30-12.docx	No		Printable Only
Instruction			#1 - IG_I6 - Tribal Input_R1_Draft_11-30-12.docx	No		Printable Only

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 %

	Requested	Previously Approved
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	476	476
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
GenIC #1 - Supporting Statement (Initial Application)	GenIC # 1 - Supporting Statement Initial Application Templates [rev 03-28-2016 by OSORA PRA].docx	03/30/2016

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