Information Collection

GenIC #1 (Revision) - CHIP Annual Report Template System (CARTS)

IC 243222 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⚠️ Notice: This information collection may be referencing outdated material.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 #1 GenIC #1 (Revision) - CHIP Annual Report Template System (CARTS)	Form and Instruction
CMS-10398 #1 CHIP Annual Report Template System (CARTS) Attachment A - CARTS Template Clean_Disclosure.docx	Form and Instruction
GenIC # 1 - CARTS Generic Supporting Statement (version 3).docx GenIC # 1 - Generic Supporting Statement	IC Document
Attachment B - CARTS Template Crosswalk.docx Crosswalk: CHIP Annual Report Template System (CARTS)	IC Document
Attachment C - CARTS Template Track Changes.docx Track Changes: CHIP Annual Report Template System (CARTS)	IC Document

IC Title:

GenIC #1 (Revision) - CHIP Annual Report Template System (CARTS)

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
Form and Instruction	CMS-10398 #1	CHIP Annual Report Template System (CARTS)	Attachment A - CARTS Template Clean_Disclosure.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

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	56	56
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
GenIC # 1 - Generic Supporting Statement	GenIC # 1 - CARTS Generic Supporting Statement (version 3).docx	08/19/2020
Crosswalk: CHIP Annual Report Template System (CARTS)	Attachment B - CARTS Template Crosswalk.docx	08/19/2020
Track Changes: CHIP Annual Report Template System (CARTS)	Attachment C - CARTS Template Track Changes.docx	08/19/2020

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