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 281905 under ICR 202610-0938-013 · OMB 0938-1148.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form GenIC #34 Title XXI State Plan Template [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
GenIC #34 Title XXI State Plan Template (71103) 0938-1148 #34 template Clean_Title XXI CHIP State Plan Template_Sept 2026 Updates.docx	Form and Instruction
GenIC 34 - Generic Supporting Statement (2026 version 3).docx Generic Supporting Statement	IC Document
(71103) 0938-1148 #34 Crosswalk_Title XXI CHIP State Plan Template_71103 Changes.pdf CROSSWALK: Title XXI State Plan Template	IC Document
(71103) 0938-1148 #34 template Redline_Title XXI CHIP State Plan Template_June 2026.pdf REDLINE: Title XXI State Plan Template	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: Modified

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	GenIC #34				Yes	Yes	Fillable Fileable

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: 41

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	82	82
Annual IC Time Burden (Hours)	168	168
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement		08/11/2026
CROSSWALK: Title XXI State Plan Template		08/11/2026
REDLINE: Title XXI State Plan Template		08/11/2026

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

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