Information Collection

[Medicaid] GenIC #34 (Revised): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program

IC 262311 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⚠️ Notice: This information collection may be referencing outdated material.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 #34 [Medicaid] GenIC #34 (Revised): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program	Form and Instruction
Form CMS-10398 #34 [Medicaid] GenIC #34 (Revised): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program	Form and Instruction
Draft title-xxi-state-plan-template Childrens Vaccine Assurances FINAL (REDLINE).docx	Other-Track Change: Title XXI State
Draft title-xxi-state-plan-template Childrens Vaccine Assurances FINAL (REDLINE).docx	Other-Track Change: Title XXI State
CMS-10398 #34 Title XXI State Plan Template 34 - Draft title-xxi-state-plan-template Childrens Vaccine Assurances FINAL (CLEAN)8-10-23.pdf	Form and Instruction
CMS-10398 #34 Title XXI State Plan Template 34 - Draft title-xxi-state-plan-template Childrens Vaccine Assurances FINAL (CLEAN)8-10-23.pdf	Form and Instruction
GenIC # 34 - Generic Supporting Statement (2023 version 5).docx Generic Supporting Statement	IC Document
GenIC # 34 - Generic Supporting Statement (2023 version 5).docx Generic Supporting Statement	IC Document
Vaccine SHO #23-003.pdf State Health Official (SHO) Letter # 23-003	IC Document
Vaccine SHO #23-003.pdf State Health Official (SHO) Letter # 23-003	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

[Medicaid] GenIC #34 (Revised): Model Application Template and Instructions for State Child Health Plan Under Title XXI of the Social Security Act, State Children's Health Insurance Program

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 and Instruction	CMS-10398 #34	Title XXI State Plan Template	34 - Draft title-xxi-state-plan-template Childrens Vaccine Assurances FINAL (CLEAN)8-10-23.pdf		Yes	Yes	Fillable Fileable
Other-Track Change: Title XXI State Plan Template			Draft title-xxi-state-plan-template Childrens Vaccine Assurances FINAL (REDLINE).docx		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: 40

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	40	40
Annual IC Time Burden (Hours)	160	160
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement	GenIC # 34 - Generic Supporting Statement (2023 version 5).docx	09/22/2023
State Health Official (SHO) Letter # 23-003	Vaccine SHO #23-003.pdf	09/22/2023

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