Information Collection

Quarterly Reporting

IC 197131 under ICR 201106-0938-010 · OMB 0938-1132.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10373 Quarterly Reporting	Form and Instruction
CMS-10373 Instrument CMS-10373.REVISED Instrument.xls	Form and Instruction
CMS-10373 Instructions CMS-10373.REVISED Instructions.doc	Form and Instruction

IC Title:

Quarterly Reporting

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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

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 and Instruction	CMS-10373	Instrument	CMS-10373.REVISED Instrument.xls		No	No	Fillable Fileable
Form and Instruction	CMS-10373	Instructions	CMS-10373.REVISED Instructions.doc		No	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 %

table that charts list of burden
	Approved	Previously Approved
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

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.