Information Collection

Data Collection Report (Initial Submission)

IC 193767 under ICR 201107-0938-017 · OMB 0938-1097.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1097 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10333 Data Collection Report (Initial Submission)	Form and Instruction
CMS-10333 Screenshot CMS-10333.Screenshots.pdf	Form and Instruction

IC Title:

Data Collection Report (Initial Submission)

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:

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-10333	Screenshot	CMS-10333.Screenshots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

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	40	-11	51
Annual IC Time Burden (Hours)	2,000	-550	2,550
Annual IC Cost Burden (Dollars)	51,600	-14,190	65,790

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.