Information Collection

State Children's Health Insurance Program and Supporting Regulations in 42 CFR 457.525, 457.740, and 457.1180

IC 8644 under ICR 202411-0938-002 · OMB 0938-0841.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-308 Statistical Enrollment Reports Screenshots (Forms: CMS-21E; CMS-64.21E; CMS-64.EC; CMS-21PW; and Form Gender, Race, Ethnicity) State Children's Health Insurance Program and Supporting Regulations in 42 CFR 457.525, 457.740, and 457.1180	Form
SEDSInstructions.pdf	Instruction
SEDSInstructions.pdf	Instruction
CMS-R-308 Statistical Enrollment Reports Screenshots (Forms: CMS-2 Complete SEDS Report_Example.pdf	Form
CMS-R-308 Statistical Enrollment Reports Screenshots (Forms: CMS-2 Complete SEDS Report_Example.pdf	Form

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: 42 CFR 457.525 42 CFR 457.350 42 CFR 457.740 42 CFR 457.1180

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					Yes	No	Printable Only
Form	CMS-R-308				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

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	Previously Approved
Annual Number of Responses for this IC	16,024,071	16,024,071
Annual IC Time Burden (Hours)	803,280	803,280
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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