GenIC #7 (Extension w/o change): Cycle IV (AI/AN Round II Outreach & Enrollment Grant Final Report Addendum) and Cycle V (Connecting Kids to Coverage Outreach and Enrollment Semi-Annual and Final

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⚠️ Notice: This information collection may be referencing outdated material.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 #7 GenIC #7 (Extension w/o change): Cycle IV (AI/AN Round II Outreach & Enrollment Grant Final Report Addendum) and Cycle V (Connecting Kids to Coverage Outreach and Enrollment Semi-Annual and Final Form and Instruction
CMS-10398 #7 Cycle Va. Connecting Kids to Coverage Semi-Annual Report 7 - Cycle IV _Part One Final_ReportingTemplate.docx Form and Instruction
CMS-10398 #7 Cycle Vb. Connecting Kids to Coverage Final Report Templ 7 - Cycle IV Final Report Addendum.doc Form and Instruction
CMS-10398 #7 Cycle IV AI/AN Round II Outreach & Enrollment Grant Fina 7 - Cycle Va Appendix A.1 Semiannual reporting template 2016 11 23.docx Form and Instruction
CMS-10398 #7 Cycle IV AI/AN Round II Outreach & Enrollment Grant Fina 7 - Cycle Vb Final reporting template 2016 11 23 .docx Form and Instruction
7 - Supporting Statement CHIPRA.docx GenIC #7 - Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	GenIC #7 (Extension w/o change): Cycle IV (AI/AN Round II Outreach & Enrollment Grant Final Report Addendum) and Cycle V (Connecting Kids to Coverage Outreach and Enrollment Semi-Annual and Final	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10398 #7	Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report (Formerly Known as the Semi-Annual Report)	7 - Cycle Va Appendix A.1 Semiannual reporting template 2016 11 23.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #7	Cycle Va. Connecting Kids to Coverage Semi-Annual Report Template	7 - Cycle IV _Part One Final_ReportingTemplate.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #7	Cycle Vb. Connecting Kids to Coverage Final Report Template	7 - Cycle IV Final Report Addendum.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #7	Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report Addendum	7 - Cycle Vb Final reporting template 2016 11 23 .docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 48	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	202	202
Annual IC Time Burden (Hours)	3,388	3,388
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
GenIC #7 - Supporting Statement	7 - Supporting Statement CHIPRA.docx	12/29/2017

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