Information Collection

Application and Eligibility Burden

IC 200520 under ICR 201112-0938-007 · OMB 0938-1095.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10334 Application and Eligibility Burden	Form and Instruction
CMS-10334 PCIP Application CMS-10334.Draft PCIP Application.doc	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-10334	PCIP Application	CMS-10334.Draft PCIP Application.doc		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	50,000	50,000
Annual IC Time Burden (Hours)	54,500	54,500
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.