Information Collection

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

IC 229607 under ICR 201712-0938-019 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

View Information Collection (IC)

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:

table that charts list of 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

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	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

table that charts IC Documents
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.