Information Collection

GenIC #85 (New): 3.1-M State Plan Amendment (SPA) Templates for Eligible Juveniles Who are Inmates of a Public Institution

IC 272763 under ICR 202409-0938-028 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Attachment 3.1-M p Attestation for Mandatory Coverage of Eligible Juveniles GenIC #85 (New): 3.1-M State Plan Amendment (SPA) Templates for Eligible Juveniles Who are Inmates of a Public Institution	Form
Form Attachment 3.1-M p Attestation for Optional Coverage of Eligible Juveniles GenIC #85 (New): 3.1-M State Plan Amendment (SPA) Templates for Eligible Juveniles Who are Inmates of a Public Institution	Form
Form Supplement to Atta Targeted Case Management (TCM) for Mandatory Coverage of Eligible Juveniles GenIC #85 (New): 3.1-M State Plan Amendment (SPA) Templates for Eligible Juveniles Who are Inmates of a Public Institution	Form
Attachment 3.1-M p Attestation for Mandatory Coverage of Eligible Juveniles 5121 SPA Attestation Attachment 3.1-M Page 1 and 2 template - 508.pdf	Form
Attachment 3.1-M p Attestation for Optional Coverage of Eligible Juveniles Attachment 5122 SPA Attestation 3.1-M Page 3 template.docx - 508.pdf	Form
Supplement to Atta Targeted Case Management (TCM) for Mandatory Coverage of 5121 TCM Supplement 1 to Attachment 3.1 08-15-24 - 508.pdf	Form
GenIC 85 - Generic Supporting Statement (2024 version 5).docx Generic Supporting Statement	IC Document
SHO Letter 24-004.pdf SHO Letter 24-004	IC Document

IC Title:

GenIC #85 (New): 3.1-M State Plan Amendment (SPA) Templates for Eligible Juveniles Who are Inmates of a Public Institution

Agency IC Tracking Number:

CMCS

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Attachment 3.1-M pages 1 and 2	Yes	Yes	Fillable Fileable
Form	Attachment 3.1-M page 3	Yes	Yes	Fillable Fileable
Form	Supplement to Attachment 3.1	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

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
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	168	168
Annual IC Time Burden (Hours)	4,872	4,872
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement		12/03/2024
SHO Letter 24-004		12/03/2024

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

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