OMB.report

Federal forms, ICRs, and supporting documents

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.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form CMS-10398 #7
Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report (Formerly Known as the Semi-Annual Report) 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
Form CMS-10398 #7
Cycle Va. Connecting Kids to Coverage Semi-Annual Report Template 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
Form CMS-10398 #7
Cycle Vb. Connecting Kids to Coverage Final Report Template 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
Form CMS-10398 #7
Cycle IV AI/AN Round II Outreach & Enrollment Grant Final Report Addendum 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)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL 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


table that charts list of burden
  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 202 0 202 0 0 0
Annual IC Time Burden (Hours) 3,388 0 3,388 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 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.