GenIC #1 (Extension w/o change): CHIP Annual Report Template System (CARTs)

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10398 #1 GenIC #1 (Extension w/o change): CHIP Annual Report Template System (CARTs) Form and Instruction
CMS-10398 #1 Framework for the Annual Report of the Children’s Health 1 - CARTS Template.doc Form and Instruction
1 - Final Supporting Statement CARTS.docx GenIC #1 - Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	GenIC #1 (Extension w/o change): CHIP Annual Report Template System (CARTs)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10398 #1	Framework for the Annual Report of the Children’s Health Insurance Plans Under Title XXI of the Social Security Act	1 - CARTS Template.doc		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: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	2,240	2,240
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
GenIC #1 - Supporting Statement	1 - Final Supporting Statement CARTS.docx	12/29/2017

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