Information Collection

2018 016 CMS - InsureKidsNow_20180810

IC 233184 under ICR 201805-1090-003 · OMB 1090-0008.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1090-0008 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 016 2018 016 CMS - InsureKidsNow_20180810	Form and Instruction
016 2018 016 CMS - InsureKidsNow_20180810 2018 016 CMS - InsureKidsNow_20180810.xlsx	Form and Instruction
1090-0008 Survey Mapping Document CMS.docx 1090-0008 Survey Mapping Document CMS	IC Document
1090-0008 Generic Clearance Request Form_USDHHS CMS_InsureKidsNow.gov Informational Survey.pdf 1090-0008 Generic Clearance Request Form_USDHHS CMS_InsureKidsNow.gov Informational Survey	IC Document

IC Title:

2018 016 CMS - InsureKidsNow_20180810

Agency IC Tracking Number:

016

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	016	2018 016 CMS - InsureKidsNow_20180810	2018 016 CMS - InsureKidsNow_20180810.xlsx		Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	3,600	3,600
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
1090-0008 Survey Mapping Document CMS	1090-0008 Survey Mapping Document CMS.docx	09/25/2018
1090-0008 Generic Clearance Request Form_USDHHS CMS_InsureKidsNow.gov Informational Survey	1090-0008 Generic Clearance Request Form_USDHHS CMS_InsureKidsNow.gov Informational Survey.pdf	09/25/2018

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