Information Collection

Quarterly Reporting

IC 197131 under ICR 201103-0938-018 · OMB 0938-1132.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1132 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10373 Quarterly Reporting Form and Instruction
CMS-10373 Instructions CMS-10373.REVISED Instructions.doc Form and Instruction
CMS-10373 Instrument CMS-10373.REVISED Instrument.xls Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Quarterly Reporting	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 158.110(b)(2)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10373	Instrument	CMS-10373.REVISED Instrument.xls		No		Fillable Fileable
Form and Instruction	CMS-10373	Instructions	CMS-10373.REVISED Instructions.doc		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 75	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	1,125	1,125
Annual IC Time Burden (Hours)	69,750	69,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.