Information Collection

States - Data Collection

IC 199275 under ICR 201212-0938-005 · OMB 0938-1086.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1086 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10320 States - Data Collection	Form and Instruction
CMS-10320 CMS-10320.FINAL State Instructions and Instrument CMS-10320.FINAL State Instructions and Instrument (5-5-10)[1].pdf	Form and Instruction
CMS-10320 CMS-10320 Appendix_E_StateRequirements CMS-10320 Appendix_E_StateRequirements.pdf	Form and Instruction

IC Title:

States - Data Collection

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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-10320	CMS-10320.FINAL State Instructions and Instrument	CMS-10320.FINAL State Instructions and Instrument (5-5-10)[1].pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10320	CMS-10320 Appendix_E_StateRequirements	CMS-10320 Appendix_E_StateRequirements.pdf		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 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	400	400
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.