Information Collection

SSO Report of State Buy-in Problems

IC 221460 under ICR 201908-0938-014 · OMB 0938-0035.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0035 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-1957 SSO Report of State Buy-in Problems	Form
CMS-1957 SSO Report of State Buy-In Problem CMS-1957-508.pdf	Form

IC Title:

SSO Report of State Buy-in Problems

Agency IC Tracking Number:

CMS-1957

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 407.40

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	CMS-1957	SSO Report of State Buy-In Problem	CMS-1957-508.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,854

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	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	5,854	1,918	3,936
Annual IC Time Burden (Hours)	1,951	639	1,312
Annual IC Cost Burden (Dollars)	0	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.