Information Collection

State Flexibility Grants Activities

IC 235550 under ICR 201904-0938-001 · OMB 0938-1366.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1366 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10657 State Flexibility Grants Activities	Form and Instruction
CMS-10657 State Flexibility Grant Annual Report Template CMS-10657 - State Flexibility Grant Annual Report Template.pdf	Form and Instruction
CMS-10657 State Flexibility Grant Quarterly Report Template CMS-10657 - State Flexibility Grant Quarterly Report Template.pdf	Form and Instruction
CMS-10657 State Flexibility Grant Final Report Template CMS-10657 - State Flexibility Grant Final Report Template.pdf	Form and Instruction

IC Title:

State Flexibility Grants Activities

Agency IC Tracking Number:

10657

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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-10657	State Flexibility Grant Annual Report Template	CMS-10657 - State Flexibility Grant Annual Report Template.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10657	State Flexibility Grant Quarterly Report Template	CMS-10657 - State Flexibility Grant Quarterly Report Template.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10657	State Flexibility Grant Final Report Template	CMS-10657 - State Flexibility Grant Final Report Template.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 31

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	155	155
Annual IC Time Burden (Hours)	2,108	2,108
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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