Information Collection

Administrative Requirements for Section 6071 of the DRA (CMS-10249)

IC 186838 under ICR 201112-0938-010 · OMB 0938-1053.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1053 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
File_Layout_for_MFP_Finders_File.pdf	Instruction
MFP_QoL_Final_version_English.pdf	Instruction
File_Layout_for_MFP_Program_Participation_Data_File.pdf	Instruction
File_Layout_for_MFP_Services_File.pdf	Instruction
CMS-10249 MFP Grant Program 2011-10-12 MFP 2011 1st Period Screen Shots.pdf	Form
CMS-10249 Semi-Annual Progress Report 2011_1st_Period_Test_Progress_Rpt.pdf	Form and Instruction

IC Title:

Administrative Requirements for Section 6071 of the DRA (CMS-10249)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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
Instruction			MFP_QoL_Final_version_English.pdf	Yes	No	Fillable Printable
Instruction			File_Layout_for_MFP_Program_Participation_Data_File.pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-10249	Semi-Annual Progress Report	2011_1st_Period_Test_Progress_Rpt.pdf	Yes	Yes	Fillable Printable
Instruction			File_Layout_for_MFP_Services_File.pdf	Yes	No	Fillable Printable
Form	CMS-10249	MFP Grant Program	2011-10-12 MFP 2011 1st Period Screen Shots.pdf	Yes	Yes	Fillable Fileable
Instruction			File_Layout_for_MFP_Finders_File.pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 47

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	106,269	105,965	304
Annual IC Time Burden (Hours)	39,058	28,664	10,394
Annual IC Cost Burden (Dollars)	0	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.