Information Collection

GenIC #53 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Guide for Developing Implementation Plan Protocols

IC 230306 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⚠️ Notice: This information collection may be referencing outdated material.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 #53 GenIC #53 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Guide for Developing Implementation Plan Protocols	Form and Instruction
53 - Opioid and other SUD 1115s smd #17-003.pdf	Other-SMD Letter 17-003 (Strategies
CMS-10398 #53 Section 1115 Substance Use Disorder (SUD) Demonstration: 53 - SUD Implementation Plan Template 11 17 2017 [rev OSORA PRA].docx	Form and Instruction
GenIC 53 - Supporting Statement [rev#3 12-14-2017 by OSORA PRA].docx Supporting Statement	IC Document

IC Title:

GenIC #53 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Guide for Developing Implementation Plan Protocols

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10398 #53	Section 1115 Substance Use Disorder (SUD) Demonstration: Guide for Developing Implementation Plan Protocols	53 - SUD Implementation Plan Template 11 17 2017 [rev OSORA PRA].docx		Yes	Yes	Fillable Fileable
Other-SMD Letter 17-003 (Strategies to Address the Opioid Epidemic)			53 - Opioid and other SUD 1115s smd #17-003.pdf		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 49

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
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	49	49
Annual IC Time Burden (Hours)	784	784
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement	GenIC 53 - Supporting Statement [rev#3 12-14-2017 by OSORA PRA].docx	03/01/2018

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