Information Collection

State Flexibility Grant II - Reporting

IC 235550 under ICR 202112-0938-016 · OMB 0938-1366.

Documents and Forms

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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10657	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10657	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10657	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 29

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	145	-10	155
Annual IC Time Burden (Hours)	1,972	-136	2,108
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.

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