Information Collection

GenIC #57 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates

IC 236005 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⚠️ Notice: This information collection may be referencing outdated material.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
Downloading 1115 Monitoring Report Templates.docx cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/	Instruction
Overview of the Standardized Monitoring Report Process.docx cvpcorp-1115pmda.adobeconnect.com/pqopfoy48idv/	Instruction
Populating and Submitting Monitoring Templates.docx cvpcorp-1115pmda.adobeconnect.com/pklt7cdlhgjl/	Instruction
1115 SUD Monitoring Protocol Template (version 4).docx	Instruction
SUD Monitoring Protocol Template Instructions (version 4).docx	Instruction
SUD Monitoring Report Template Instructions (version 4).docx	Instruction
CMS-10398 #57 1115 SUD Metrics Template Copy of Copy of 1115 SUD Metrics Workbook 3_1 (version 4).xlsx	Form
1 1115 SUD Monitoring Report Template 1115 SUD Monitoring Report Template (version 4).docx	Form
smd #17-003.pdf State Medicaid Directors letter #17-003	IC Document
Supporting Statement A Health Policy Booklets Local Gov 031119.docx Supporting Statement A	IC Document

IC Title:

GenIC #57 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates

Agency IC Tracking Number:

CMCS

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
Instruction			SUD Monitoring Protocol Template Instructions (version 4).docx		Yes	No	Printable Only
Instruction			Populating and Submitting Monitoring Templates.docx	https://cvpcorp-1115pmda.adobeconnect.com/pklt7cdlhgjl/	Yes	No	Printable Only
Instruction			Overview of the Standardized Monitoring Report Process.docx	https://cvpcorp-1115pmda.adobeconnect.com/pqopfoy48idv/	Yes	No	Printable Only
Instruction			Downloading 1115 Monitoring Report Templates.docx	https://cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/	Yes	Yes	Printable Only
Form	1	1115 SUD Monitoring Report Template	1115 SUD Monitoring Report Template (version 4).docx		Yes	Yes	Fillable Fileable
Form	CMS-10398 #57	1115 SUD Metrics Template	Copy of Copy of 1115 SUD Metrics Workbook 3_1 (version 4).xlsx		Yes	Yes	Fillable Fileable
Instruction			1115 SUD Monitoring Protocol Template (version 4).docx		Yes	No	Printable Only
Instruction			SUD Monitoring Report Template Instructions (version 4).docx		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35

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	455	455
Annual IC Time Burden (Hours)	10,080	10,080
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
State Medicaid Directors letter #17-003	smd #17-003.pdf	05/07/2019
Supporting Statement A	Supporting Statement A Health Policy Booklets Local Gov 031119.docx	05/20/2019

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