Information Collection

Survey of Plan Sponsors (Private Entities)

IC 200146 under ICR 201111-0938-007 · OMB 0938-1150.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1150 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10408 Survey of Plan Sponsors (Private Entities)	Form
CMS-10408.Final Draft Survey Instructions (11-23-11).pdf	Instruction
CMS-10408 Final Survey CMS_Sample_Survey.pdf	Form

IC Title:

Survey of Plan Sponsors (Private Entities)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 149.200

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	CMS-10408	Final Survey	CMS_Sample_Survey.pdf		Yes	No	Fillable Printable
Instruction			CMS-10408.Final Draft Survey Instructions (11-23-11).pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Early Retiree Reinsurance Program

FR Citation: 75 FR 31440

Number of Respondents: 1,038

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

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	1,038	1,038
Annual IC Time Burden (Hours)	11,418	11,418
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.