Information Collection

Waiver Application

IC 195248 under ICR 201805-0938-009 · OMB 0938-1114.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

Waiver Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 158.322 45 CFR 158.321(d)(1)-(13) 45 CFR 158.321(c) 45 CFR 158.321(a) 45 CFR 158.321(b) 45 CFR 158.323

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 22

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	22	22
Annual IC Time Burden (Hours)	3,080	3,080
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.