Information Collection

State Requirements and Burden

IC 216803 under ICR 202308-0938-005 · OMB 0938-1282.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1282 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	State Requirements and Burden	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 457.760 42 CFR 457.1201 42 CFR 457.1206 42 CFR 457.1207 42 CFR 457.1208 42 CFR 457.1210 42 CFR 457.1214 42 CFR 457.1216 42 CFR 457.1218 42 CFR 457.1224 42 CFR 457.1260 42 CFR 457.1205 42 CFR 457.1222 42 CFR 457.1230 42 CFR 457.1223 42 CFR 457.1240 42 CFR 457.1250 42 CFR 457.1270 42 CFR 457.1285

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: 62	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 95 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	379,831	2,674	377,157
Annual IC Time Burden (Hours)	82,968	11,311	71,657
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.