Information Collection

GenIC #57 (Revision): Medicaid Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates

IC 252106 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⚠️ Notice: This information collection may be referencing outdated material.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
SUD_MonProtocolInstr.v4.0_PRA.pdf	Instruction
SUD_MonProtocolInstr.v4.0_PRA.pdf	Instruction
SUD_MonReportInstr.v4.0_PRA.pdf	Instruction
SUD_MonReportInstr.v4.0_PRA.pdf	Instruction
Video - Downloading 1115 Demonstration Monitoring Report Templates.docx cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/	Instruction
Video - Downloading 1115 Demonstration Monitoring Report Templates.docx cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/	Instruction
CMS-10398 #57 Monitoring Protocol Template SUD_MonProtocolTemp.v4.0_PRA.docx	Form
CMS-10398 #57 Monitoring Protocol Template SUD_MonProtocolTemp.v4.0_PRA.docx	Form
CMS-10398 #57 Monitoring Protocol Workbook SUD_MonProtocolWB.v6.0_PRA.xlsx	Form and Instruction
CMS-10398 #57 Monitoring Protocol Workbook SUD_MonProtocolWB.v6.0_PRA.xlsx	Form and Instruction
CMS-10398 #57 Monitoring Report Template SUD_MonReportTemp.v4.0_PRA.docx	Form
CMS-10398 #57 Monitoring Report Template SUD_MonReportTemp.v4.0_PRA.docx	Form
CMS-10398 #57 Monitoring Report Workbook SUD_MonReportWB.v6.0_PRA.xlsx	Form and Instruction
CMS-10398 #57 Monitoring Report Workbook SUD_MonReportWB.v6.0_PRA.xlsx	Form and Instruction
57 - Generic Supporting Statement (2022 version 6).docx Generic Supporting Statement	IC Document
57 - Generic Supporting Statement (2022 version 6).docx Generic Supporting Statement	IC Document
SUD Crosswalk 2022_Monitoring Protocol Instructions.xlsx Crosswalk: Monitoring Protocol Instructions	IC Document
SUD Crosswalk 2022_Monitoring Protocol Instructions.xlsx Crosswalk: Monitoring Protocol Instructions	IC Document
SUD Crosswalk 2022_Monitoring Protocol Template.xlsx Crosswalk: Monitoring Protocol Template	IC Document
SUD Crosswalk 2022_Monitoring Protocol Template.xlsx Crosswalk: Monitoring Protocol Template	IC Document
SUD Crosswalk 2022_Monitoring Protocol Workbook.xlsx Crosswalk: Monitoring Protocol Workbook	IC Document
SUD Crosswalk 2022_Monitoring Protocol Workbook.xlsx Crosswalk: Monitoring Protocol Workbook	IC Document
SUD Crosswalk 2022_Monitoring Report Instructions.xlsx Crosswalk: Monitoring Report Instructions	IC Document
SUD Crosswalk 2022_Monitoring Report Instructions.xlsx Crosswalk: Monitoring Report Instructions	IC Document
SUD Crosswalk 2022_Monitoring Report Template.xlsx Crosswalk: Monitoring Report Template	IC Document
SUD Crosswalk 2022_Monitoring Report Template.xlsx Crosswalk: Monitoring Report Template	IC Document
SUD Crosswalk 2022_Monitoring Report Workbook.xlsx Crosswalk: Monitoring Report Workbook	IC Document
SUD Crosswalk 2022_Monitoring Report Workbook.xlsx Crosswalk: Monitoring Report Workbook	IC Document
SMDL 17-003.pdf SMDL #17-003	IC Document
SMDL 17-003.pdf SMDL #17-003	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

GenIC #57 (Revision): Medicaid Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates

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
Instruction			SUD_MonProtocolInstr.v4.0_PRA.pdf		Yes	Yes	Printable Only
Form	CMS-10398 #57	Monitoring Protocol Template	SUD_MonProtocolTemp.v4.0_PRA.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #57	Monitoring Protocol Workbook	SUD_MonProtocolWB.v6.0_PRA.xlsx		Yes	Yes	Fillable Fileable
Instruction			SUD_MonReportInstr.v4.0_PRA.pdf		Yes	Yes	Printable Only
Form	CMS-10398 #57	Monitoring Report Template	SUD_MonReportTemp.v4.0_PRA.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #57	Monitoring Report Workbook	SUD_MonReportWB.v6.0_PRA.xlsx		Yes	Yes	Fillable Fileable
Instruction			Video - Downloading 1115 Demonstration Monitoring Report Templates.docx	https://cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/	Yes	No	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35

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	596	596
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	57 - Generic Supporting Statement (2022 version 6).docx	03/15/2022
Crosswalk: Monitoring Protocol Instructions	SUD Crosswalk 2022_Monitoring Protocol Instructions.xlsx	03/15/2022
Crosswalk: Monitoring Protocol Template	SUD Crosswalk 2022_Monitoring Protocol Template.xlsx	03/15/2022
Crosswalk: Monitoring Protocol Workbook	SUD Crosswalk 2022_Monitoring Protocol Workbook.xlsx	03/15/2022
Crosswalk: Monitoring Report Instructions	SUD Crosswalk 2022_Monitoring Report Instructions.xlsx	03/15/2022
Crosswalk: Monitoring Report Template	SUD Crosswalk 2022_Monitoring Report Template.xlsx	03/15/2022
Crosswalk: Monitoring Report Workbook	SUD Crosswalk 2022_Monitoring Report Workbook.xlsx	03/15/2022
SMDL #17-003	SMDL 17-003.pdf	03/15/2022

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