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)

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

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:

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

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 %

	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

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.