Information Collection

States - Data submission

IC 192725 under ICR 201103-0938-016 · OMB 0938-1086.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1086 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 00 States - Data submission	Form
CMS-10320 CMS-10320.FINAL State Instructions and Instrument (5-5-1 CMS-10320.FINAL State Instructions and Instrument (5-5-10).pdf	Form and Instruction
00 HIOS Issuer Data Entry Form hios_issuer_data_entry_form_05022011.xls	Form

IC Title:

States - Data submission

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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	00	HIOS Issuer Data Entry Form	hios_issuer_data_entry_form_05022011.xls		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10320	CMS-10320.FINAL State Instructions and Instrument (5-5-10).	CMS-10320.FINAL State Instructions and Instrument (5-5-10).pdf		Yes	No	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	8	8
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.