Information Collection

Resource Report

IC 193279 under ICR 201006-0938-006 · OMB 0938-0850.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0850 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10028 RESOURCE REPORT	Form
CMS-10028 Public and Media Activity Report Form (PAM) CMS-10028.Public_Media_Form_120209_Certified.pdf	Form

IC Title:

RESOURCE REPORT

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	CMS-10028	Public and Media Activity Report Form (PAM)	CMS-10028.Public_Media_Form_120209_Certified.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54

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	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	54	54
Annual IC Time Burden (Hours)	108	108
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.