Information Collection

GenIC #7 (Revised): Cycle Vb (Final Report Template for the Round III AI/AN Cooperative Agreements), Cycle Va (Semi-Annual Template), and Cycle Vb (Monthly and Final Report Templates)

IC 236649 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⚠️ Notice: This information collection may be referencing outdated material.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 (Revised): Cycle Vb (Final Report Template for the Round III AI/AN Cooperative Agreements), Cycle Va (Semi-Annual Template), and Cycle Vb (Monthly and Final Report Templates)	Form
CMS-10398 #7 HEALTHY KIDS Cycle Va: Semi-Annual Report Template (qual HEALTHY KIDS Cycle Va SAR Template with PRA Disclosure.docx	Form
CMS-10398 #7 HEALTHY KIDS Cycle Vb: Final Report Template (qualitativ HEALTHY KIDS Cycle Vb Final SAR Template with PRA Disclosure.docx	Form
CMS-10398 #7 MACRA Cycle Vb, Round III: Final Report Template MACRA Cycle Vb Round III Final Report Template.docx	Form
CMS-10398 #7 HEALTHY KIDS Cycle Vb: Monthly Report Targets vs Other ( Monthly report - targets vs other v9_1.11.19.xlsm	Form
CMS-10398 #7 HEALTHY KIDS Cycle Vb: Monthly Report (quantitative repo Monthly report v41_1.11.19.xlsm	Form
Crosswalk.xlsx Crosswalk	IC Document
GenIC 7 - Supporting Statement (2019 version 5).docx GenIC Supporting Statement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

GenIC #7 (Revised): Cycle Vb (Final Report Template for the Round III AI/AN Cooperative Agreements), Cycle Va (Semi-Annual Template), and Cycle Vb (Monthly and Final Report 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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398 #7	HEALTHY KIDS Cycle Va: Semi-Annual Report Template (qualitative report)	HEALTHY KIDS Cycle Va SAR Template with PRA Disclosure.docx	Yes	Yes	Fillable Fileable
Form	CMS-10398 #7	HEALTHY KIDS Cycle Vb: Final Report Template (qualitative report)	HEALTHY KIDS Cycle Vb Final SAR Template with PRA Disclosure.docx	Yes	Yes	Fillable Fileable
Form	CMS-10398 #7	MACRA Cycle Vb, Round III: Final Report Template	MACRA Cycle Vb Round III Final Report Template.docx	Yes	Yes	Fillable Fileable
Form	CMS-10398 #7	HEALTHY KIDS Cycle Vb: Monthly Report Targets vs Other (quantitative reporting)	Monthly report - targets vs other v9_1.11.19.xlsm	Yes	Yes	Fillable Fileable
Form	CMS-10398 #7	HEALTHY KIDS Cycle Vb: Monthly Report (quantitative reporting)	Monthly report v41_1.11.19.xlsm	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: 47

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	1,634	1,634
Annual IC Time Burden (Hours)	5,258	5,258
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	Crosswalk.xlsx	08/16/2019
GenIC Supporting Statement	GenIC 7 - Supporting Statement (2019 version 5).docx	08/16/2019

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