Information Collection

Quarterly

IC 198690 under ICR 201111-0938-011 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Quarterly	Form and Instruction
CMS-10371 Quarterly Instrument 0938-1119 - Form 83 - Part II - Quarterly - Instrument.docx	Form and Instruction
CMS-10371 Quarterly Data Elements 0938-1119 - Form 83 - Part II - Quarterly - Data Elements.xlsx	Form and Instruction
CMS-10371 Quarterly Instrument Revised 0938-1119 - Form 83 - Part II - Quarterly - Instrument.docx	Form and Instruction
CMS-10371 Quarterly Data Elements Revised Copy of 0938-1119 - Form 83 - Part II - Quarterly - Data Elements.xlsx	Form and Instruction

IC Title:

Quarterly

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10371	Quarterly Instrument	0938-1119 - Form 83 - Part II - Quarterly - Instrument.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10371	Quarterly Data Elements	0938-1119 - Form 83 - Part II - Quarterly - Data Elements.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10371	Quarterly Instrument Revised	0938-1119 - Form 83 - Part II - Quarterly - Instrument.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10371	Quarterly Data Elements Revised	Copy of 0938-1119 - Form 83 - Part II - Quarterly - Data Elements.xlsx	Yes	Yes	Fillable Fileable

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	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	23,000	23,000
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.