Information Collection

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

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 #72 GenIC #72 (New): Expressions of Interest in the Infant Well-Child Visit Affinity Group	Form and Instruction
Form CMS-10398 #72 GenIC #72 (New): Expressions of Interest in the Infant Well-Child Visit Affinity Group	Form and Instruction
well-child-visit-ag-fact-sheet.pdf	Other-Fact Sheet
well-child-visit-ag-fact-sheet.pdf	Other-Fact Sheet
CMS-10398 #72 Expression of Interest Form well-child-visit-ag-interest-form.pdf	Form and Instruction
CMS-10398 #72 Expression of Interest Form well-child-visit-ag-interest-form.pdf	Form and Instruction
GenIC #72 - Generic Supporting Statement (2021 version 3).docx Generic Supporting Statement	IC Document
GenIC #72 - Generic Supporting Statement (2021 version 3).docx Generic Supporting Statement	IC Document

IC Title:

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

Agency IC Tracking Number:

CMCS

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	140	140
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.