Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI (CMS-21 and 21B)

Forms and Documents

Document Name	Status
Form CMS-21 Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI Form and Instruction	Modified
REASON FOR NO CHANGE IN BURDEN.doc Supplementary Document	2011-03-30
Comments CMS.21 [to OMB].doc Supplementary Document	2011-03-01
CMS-21and21B - Crosswalk.xlsx Supplementary Document	2011-03-01
CMS-21 Supporting Statement [03_01_11] 002.doc Supporting Statement A	2011-03-01

IC Document Collections

IC ID	Document Title	Status
8399	Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0731	ICR Reference No: 201103-0938-012
Status: Historical Active	Previous ICR Reference No: 200806-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI (CMS-21 and 21B)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/22/2011
	Date Received in OIRA: 03/21/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2014	36 Months From Approved	08/31/2011
Responses	448	0	448
Time Burden (Hours)	7,840	0	7,840
Cost Burden (Dollars)	0	0	0

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Abstract: States use the Form 21 to report budget, expenditure, and related statistical information required for implementation of the Children's Health Insurance Program.

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Authorizing Statute(s): Statute at Large: 21 Stat. 2105 Name of Statute: null
   PL: Pub.L. 105 - 33 2105 Name of Law: State Children's Health Insurance
   PL: Pub.L. 105 - 33 2105 Name of Law: Program Payments to States
   PL: Pub.L. 111 - 3 201, 202, and 211 Name of Law: Children's Health Insurance Program Reauthorization Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 76988	12/10/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 9579	02/18/2011
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Quarterly Children's Health Insurance Program Statement of Expenditures for Title XXI	CMS-21, CMS-21B	Quarterly CHIP Statement of Expenditures for the Title XXI Program ,   State CHIP Budget Report for the Title XXI Program

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	448	448	0	0	0	0
Annual Time Burden (Hours)	7,840	7,840	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $128,172

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/21/2011

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