Survey of Plan Sponsors (Private Entities)

Early Retiree Reinsurance Program: Survey of Plan Sponsors

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.