Information Collection

GenIC #100 New (Medicaid Community Engagement: Good Faith Effort Exemptions and Quarterly Reporting)

IC 281679 under ICR 202607-0938-014 · OMB 0938-1148.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
GenIC 100 - Generic Supporting Statement (CMS-2454-IFC version 6).docx Generic Supporting Statement	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 435.560

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	18	18
Annual IC Time Burden (Hours)	380	380
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement		07/28/2026

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

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