Information Collection

Public Report

IC 202383 under ICR 201205-0938-006 · OMB 0938-1168.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10424 Public Report	Form and Instruction
Form 83 Part II - Progress Report - Data Elements - CLEAN_051512_v3.pdf	Other-Data Elements
CMS-10424 Progress Report Progress_Report_Instrument.pdf	Form and Instruction

IC Title:

Public Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10424	Progress Report	Progress_Report_Instrument.pdf		Yes	Yes	Fillable Fileable
Other-Data Elements			Form 83 Part II - Progress Report - Data Elements - CLEAN_051512_v3.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

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	Program Change Due to New Statute
Annual Number of Responses for this IC	102	102
Annual IC Time Burden (Hours)	867	867
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.