Information Collection

Public Report

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.