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GenIC #72 (New): Expressions of Interest in the Infant Well-Child Visit Affinity Group

IC 248500 under ICR 202401-0938-016 · OMB 0938-1148.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Other-Fact Sheet
Other-Fact Sheet
Form and Instruction
Form and Instruction
IC Document
IC Document
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GenIC #72 (New): Expressions of Interest in the Infant Well-Child Visit Affinity Group CMCS
 
Unchanged
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10398 #72 Expression of Interest Form well-child-visit-ag-interest-form.pdf Yes Yes Fillable Fileable
Other-Fact Sheet well-child-visit-ag-fact-sheet.pdf Yes No Printable Only

Health Health Care Services

 

20 0
   
State, Local, and Tribal Governments
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 20 0 0 0 0 20
Annual IC Time Burden (Hours) 140 0 0 0 0 140
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Generic Supporting Statement GenIC #72 - Generic Supporting Statement (2021 version 3).docx 07/22/2021
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.