Information Collection

Disclosures and Review Burden (2011-2013)

IC 193861 under ICR 201106-0938-021 · OMB 0938-1099.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1099 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10338.HHS SRG on Elections.pdf	Instruction
CMS-10338.CLAS Bulletin.pdf	Instruction
CMS-10338.Technical Release and Model Notices.pdf	Instruction

IC Title:

Disclosures and Review Burden (2011-2013)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 147.136

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction	CMS-10338.Technical Release and Model Notices.pdf	Yes	Yes	Paper Only
Instruction	CMS-10338.HHS SRG on Elections.pdf	Yes	Yes	Paper Only
Instruction	CMS-10338.CLAS Bulletin.pdf	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 28,000

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	70,834,597	432,597	70,402,000
Annual IC Time Burden (Hours)	930,267	-269,733	1,200,000
Annual IC Cost Burden (Dollars)	36,775,067	-14,324,933	51,100,000

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.