Information Collection

Quarterly Reports

IC 193864 under ICR 201101-0938-004 · OMB 0938-1101.

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Information Collection (IC) Details

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IC Title:	Quarterly Reports	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection 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: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	204	-20	224
Annual IC Time Burden (Hours)	10,200	792	9,408
Annual IC Cost Burden (Dollars)	503,119	199,543	303,576

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