Information Collection

State Requirements

IC 46621 under ICR 202303-0938-014 · OMB 0938-0790.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0790 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	State Requirements	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 460.160(b) 42 CFR 460.30(a), (b), and (c) 42 CFR 460.152(a)(3) 42 CFR 460.164(e)

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: 34	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	115	115
Annual IC Time Burden (Hours)	9,828	9,828
Annual IC Cost Burden (Dollars)	0	0

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