Information Collection

States: SBE's, Federal Platform and Partnership States

IC 206071 under ICR 202204-0938-007 · OMB 0938-1187.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1187 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	States: SBE's, Federal Platform and Partnership States	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 155.705

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	40	18	22
Annual IC Time Burden (Hours)	120	54	66
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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