Information Collection

Annual Report on Home and Community-based Services Waivers

IC 43654 under ICR 202409-0938-022 · OMB 0938-0272.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-372(S) Annual Report on Home and Community-based Services Waivers	Form
CMS-372(S) Annual Report on Home and Community-Based Services (HCBS Waiver Management System 372(S) Report Screenshots - 508.pdf	Form
CMS-372(S) Annual Report Quality Section 372 Report Quality Section Updates (Screenshots).pdf	Form
2021 to 2024 Form CMS-372(S) Report Crosswalk - Track Changes - Accepted.pdf Crosswalk	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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-372(S)	Annual Report on Home and Community-Based Services (HCBS) Waivers	Waiver Management System 372(S) Report Screenshots - 508.pdf		Yes	Yes	Fillable Fileable
Form	CMS-372(S)	Annual Report Quality Section	372 Report Quality Section Updates (Screenshots).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 47

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	259	6	253
Annual IC Time Burden (Hours)	11,396	264	11,132
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	2021 to 2024 Form CMS-372(S) Report Crosswalk - Track Changes - Accepted.pdf	09/19/2024

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