Information Collection

Private Written Agreement Year 2_3_4

IC 192759 under ICR 201202-0938-004 · OMB 0938-1087.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0938-1087 Revised_Instrument Collection Instructions.docx	Instruction
CMS-10321 Revised ERRP Collection Instrument 0938-1087 Revised ERRP Collection Instrument-1.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 149.35(b)(2)

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
Instruction			0938-1087 Revised_Instrument Collection Instructions.docx		Yes	No	Fillable Fileable
Form	CMS-10321	Revised ERRP Collection Instrument	0938-1087 Revised ERRP Collection Instrument-1.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 764

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-764	764
Annual IC Time Burden (Hours)	-764	764
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.