CMS-10398 #31 Sample Template For State Settings’ Analysis

OMB Control Number 0938-1148

Expiration date: 10/31/2014

SAMPLE TEMPLATE FOR STATE SETTINGS’ ANALYSIS (Optional)

CATEGORY	STANDARD (LICENSING, CERTIFICATION, REGULATION, STATE REVIEW OF SETTINGS, ETC.)	TYPE OR NAME OF SETTING AND TOTAL NUMBER OF SETTINGS	SOURCE(S) OF EVIDENCE/EVALUATION FOR PLACEMENT IN CATEGORY	REMEDIATION STRATEGY
Settings fully align with HCB setting requirements:
With changes, settings will align with HCB setting requirements:
Presumptively non-HCB settings (for which state is submitting justification/evidence to refute presumption):
Settings do not/cannot meet HCB setting requirements (including presumptively non-HCB settings for which the state does not dispute the status

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-1148.  The time required to complete this information collection is estimated to average 42 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.