Information Collection

Employer Organization Survey

IC 200236 under ICR 201111-0938-010 · OMB 0938-1160.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10404 Employer Organization Survey	Form and Instruction
CMS-10404 Employer Organization Survey CMS-10404 - Employer Organization Surveys and Materials 2-14-12.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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-10404	Employer Organization Survey	CMS-10404 - Employer Organization Surveys and Materials 2-14-12.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51,560

Number of Respondents for Small Entity: 30,000

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	51,560	51,560
Annual IC Time Burden (Hours)	51,560	51,560
Annual IC Cost Burden (Dollars)	939,423	939,423

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.