Information Collection

SDMS Application

IC 241813 under ICR 202005-0906-001 · OMB 0906-0029.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0029 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form D SDMS Application	Form and Instruction
D SDMS Supplemental Information - Attachment D.docx SDMS Supplemental Information - Attachment D.docx	Form and Instruction

IC Title:

SDMS Application

Agency IC Tracking Number:

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	D	SDMS Supplemental Information - Attachment D.docx	SDMS Supplemental Information - Attachment D.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54

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	4,482	4,482
Annual IC Time Burden (Hours)	17,928	17,928
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.