Quarterly

Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1119 can be found here:

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.