Information Collection

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

IC 249074 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⚠️ Notice: This information collection may be referencing outdated material.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 (Nonsubstantive Change): Expressions of Interest in the Infant Well-Child Visit Affinity Group	Form
Form CMS-10398 #72 GenIC #72 (Nonsubstantive Change): Expressions of Interest in the Infant Well-Child Visit Affinity Group	Form
well-child-visit-ag-fact-sheet.pdf	Other-Affinity Group Fact Sheet
well-child-visit-ag-fact-sheet.pdf	Other-Affinity Group Fact Sheet
CMS-10398 #72 Expression of Interest Form well-child-visit-ag-interest-form.pdf	Form
CMS-10398 #72 Expression of Interest Form well-child-visit-ag-interest-form.pdf	Form
GenIC 72 - Generic Supporting Statement (2021 version 7).docx Generic Supporting Statement	IC Document
GenIC 72 - Generic Supporting Statement (2021 version 7).docx Generic Supporting Statement	IC Document
Justification for Nonsubstantive Change.docx Justification for Nonsubstantive Change	IC Document
Justification for Nonsubstantive Change.docx Justification for Nonsubstantive Change	IC Document

IC Title:

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

Agency IC Tracking Number:

CMCS

IC Status: Unchanged

Obligation to Respond: Mandatory

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	CMS-10398 #72	Expression of Interest Form	well-child-visit-ag-interest-form.pdf		Yes	Yes	Fillable Fileable
Other-Affinity Group Fact Sheet			well-child-visit-ag-fact-sheet.pdf		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)	5	5
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 7).docx	08/27/2021
Justification for Nonsubstantive Change	Justification for Nonsubstantive Change.docx	08/27/2021

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