Information Collection

State Children's Health Insurance Program and Supporting Regulations in 42 CFR 457.525, 457.740, and 457.1180

IC 8644 under ICR 202109-0938-011 · OMB 0938-0841.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0841 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
SEDSInstructions.pdf	Instruction
SEDSInstructions.pdf	Instruction
CMS-R-308 Statistical Enrollment Reports Screenshots (Forms: CMS-2 Complete SEDS Report_Example.pdf	Form
CMS-R-308 Statistical Enrollment Reports Screenshots (Forms: CMS-2 Complete SEDS Report_Example.pdf	Form
SEDS Instructions Crosswalk.pdf CROSSWALK: SEDS Instructions for Data Entry	IC Document
SEDS Instructions Crosswalk.pdf CROSSWALK: SEDS Instructions for Data Entry	IC Document
SEDS Statistical Enrollment Report Crosswalk.pdf CROSSWALK: Statistical Enrollment Reports	IC Document
SEDS Statistical Enrollment Report Crosswalk.pdf CROSSWALK: Statistical Enrollment Reports	IC Document

IC Title:

State Children's Health Insurance Program and Supporting Regulations in 42 CFR 457.525, 457.740, and 457.1180

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 457.525 42 CFR 457.350 42 CFR 457.740 42 CFR 457.1180

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
Instruction			SEDSInstructions.pdf		Yes	No	Printable Only
Form	CMS-R-308	Statistical Enrollment Reports Screenshots (Forms: CMS-21E; CMS-64.21E; CMS-64.EC; CMS-21PW; and Form Gender, Race, Ethnicity)	Complete SEDS Report_Example.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	16,024,071	6,486,795	9,537,276
Annual IC Time Burden (Hours)	803,280	324,140	479,140
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CROSSWALK: SEDS Instructions for Data Entry	SEDS Instructions Crosswalk.pdf	09/29/2021
CROSSWALK: Statistical Enrollment Reports	SEDS Statistical Enrollment Report Crosswalk.pdf	09/29/2021

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