Information Collection

Periodic Reporting

IC 198688 under ICR 201107-0938-018 · OMB 0938-1119.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1119 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10371 Periodic Reporting	Form and Instruction
0938-1119 - FOA - Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges.pdf	Instruction
CMS-10371 FOA CMS-10371.FOA document.docx	Form and Instruction

IC Title:

Periodic Reporting

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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-10371	FOA	CMS-10371.FOA document.docx		Yes	Yes	Fillable Fileable
Instruction			0938-1119 - FOA - Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges.pdf		Yes	Yes	Paper Only

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
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	10,600	10,600
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.