Information Collection

Quarterly and Monthly Reporting

IC 193921 under ICR 201007-0938-013 · OMB 0938-1100.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1100 can be found here:

Documents and Forms

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Document Name	Document Type

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IC Title:

Quarterly and Monthly Reporting

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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

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: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	612	612
Annual IC Time Burden (Hours)	14,688	14,688
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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