Data Collection Report (Initial Submission)

Consumer Assistance Program Grants

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1097 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10333 Data Collection Report (Initial Submission) Form and Instruction
CMS-10333 Appendix 1 CMS-10333 Appendix 1_Screenshots of CCIIO-Developed Database.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Data Collection Report (Initial Submission)	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10333	Appendix 1	CMS-10333 Appendix 1_Screenshots of CCIIO-Developed Database.pdf		No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 56	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	56	16	0	40
Annual IC Time Burden (Hours)	1,568	-432	0	2,000
Annual IC Cost Burden (Dollars)	0	0	-51,600	51,600

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.