Information Collection

GenIC #64 (New): Federal Meta-Analysis Support: Section 1115 Substance Use Disorder Demonstrations

IC 242071 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⚠️ Notice: This information collection may be referencing outdated material.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 #64 GenIC #64 (New): Federal Meta-Analysis Support: Section 1115 Substance Use Disorder Demonstrations	Form and Instruction
64 - Attachment 1.a. Demo Characteristics Admin Intro Email from CMS to SMD_clean.docx	Other-Introductory Email: Demonstrat
64 - Attachment 1.d. Demo Characteristics Interview Confirmation Email_clean.docx	Other-Confirmation Email: Demonstrat
64 - Attachment 1.e. Demo Characteristics Interview Outlook Invitation_clean.docx	Other-Outlook Invitation: Demonstrat
64 - Attachment 1.f. Demonstration Characteristics Interview Reminder Email_clean.docx	Other- Reminder Email: Demonstration
64 - Attachment 2.a. Email CMS to State Administrator Intro RTI Evaluation_clean.docx	Other-Introductory Email: Implementa
64 - Attachment 2.b. Implementation Interview Email Invitation_clean.docx	Other- Email Invitation: Implementat
64 - Attachment 2.c. Implementation Interview Confirmation Email_clean.docx	Other-Confirmation Email: Implementa
64 - Attachment 2.d. Implementation Interview Outlook Invitation_clean.docx	Other-Implementation Interview
64 - Attachment 2.e. Implementation Interview Reminder Email_clean.docx	Other- Reminder Email: Implementatio
CMS-10398 #64 Demonstration Characteristics Interview Email Invitation Attachment 1.b. Demonstration Characteristics Interview Email Invitation_clean_ 5June 2020.docx	Form and Instruction
CMS-10398 #64 Demonstration Characteristics Interview Questions Attachment 1.c. Demonstration Characteristics Interview Questions_clean_5 June 2020.docx	Form and Instruction
CMS-10398 #64 Implementation Interview Protocol with Instructions for Attachment 2.f. Implementation Interview Protocol with Instructions for Interviewer_clean_5 June 2020.docx	Form and Instruction
64 - Generic Supporting Statement (2020 version 4).docx Generic Supporting Statement	IC Document
64 - Supporting Statement Part B_clean_5 June 2020.docx Supporting Statement B	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

GenIC #64 (New): Federal Meta-Analysis Support: Section 1115 Substance Use Disorder Demonstrations

Agency IC Tracking Number:

CMCS

IC Status: New

Obligation to Respond: Voluntary

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 and Instruction	CMS-10398 #64	Demonstration Characteristics Interview Questions	Attachment 1.c. Demonstration Characteristics Interview Questions_clean_5 June 2020.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #64	Implementation Interview Protocol with Instructions for Interviewer	Attachment 2.f. Implementation Interview Protocol with Instructions for Interviewer_clean_5 June 2020.docx	Yes	Yes	Fillable Fileable
Other-Introductory Email: Demonstration Characteristics Interview			64 - Attachment 1.a. Demo Characteristics Admin Intro Email from CMS to SMD_clean.docx	Yes	No	Printable Only
Other-Confirmation Email: Demonstration Characteristics Interview			64 - Attachment 1.d. Demo Characteristics Interview Confirmation Email_clean.docx	Yes	No	Printable Only
Other-Outlook Invitation: Demonstration Characteristics Interview			64 - Attachment 1.e. Demo Characteristics Interview Outlook Invitation_clean.docx	Yes	No	Printable Only
Other- Reminder Email: Demonstration Characteristics Interview			64 - Attachment 1.f. Demonstration Characteristics Interview Reminder Email_clean.docx	Yes	Yes	Printable Only
Other-Introductory Email: Implementation Interview			64 - Attachment 2.a. Email CMS to State Administrator Intro RTI Evaluation_clean.docx	Yes	No	Printable Only
Other- Email Invitation: Implementation Interview			64 - Attachment 2.b. Implementation Interview Email Invitation_clean.docx	Yes	No	Printable Only
Other-Confirmation Email: Implementation Interview			64 - Attachment 2.c. Implementation Interview Confirmation Email_clean.docx	Yes	No	Printable Only
Other-Implementation Interview			64 - Attachment 2.d. Implementation Interview Outlook Invitation_clean.docx	Yes	No	Printable Only
Other- Reminder Email: Implementation Interview			64 - Attachment 2.e. Implementation Interview Reminder Email_clean.docx	Yes	No	Printable Only
Form and Instruction	CMS-10398 #64	Demonstration Characteristics Interview Email Invitation and Grid	Attachment 1.b. Demonstration Characteristics Interview Email Invitation_clean_ 5June 2020.docx	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: 27

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	54	54
Annual IC Time Burden (Hours)	162	162
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement	64 - Generic Supporting Statement (2020 version 4).docx	06/05/2020
Supporting Statement B	64 - Supporting Statement Part B_clean_5 June 2020.docx	06/05/2020

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