Information Collection

Survey of Plan Sponsors (Private Entities)

IC 200146 under ICR 201301-0938-008 · OMB 0938-1150.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10408 ERRP Survey of Plan Sponsors Survey of Plan Sponsors (Private Entities)	Form
Form CMS-10408 REVISED ERRP Survey of Plan Sponsors 11-17-11 Survey of Plan Sponsors (Private Entities)	Form
Form CMS-10408 Final Survey Survey of Plan Sponsors (Private Entities)	Form
CMS 10408_ERRP Survey of Plan Sponsors_Instructions_508.pdf	Instruction
CMS-10408 REVISED _ ERRP Survey of Plan Sponsors _ Instructions 11-17-11.docx	Instruction
CMS-10408 ERRP Survey_Email to Sponsors 11_17_11_FINAL.docx	Other-CMS-10408 ERRP Survey_Email to
CMS-10408.Final Draft Survey Instructions (11-23-11).pdf	Instruction
CMS-10408 ERRP Survey of Plan Sponsors CMS 10408_ERRP Survey of Plan Sponsors_508.pdf	Form
CMS-10408 REVISED ERRP Survey of Plan Sponsors 11-17-11 CMS-10408 REVISED ERRP Survey of Plan Sponsors 11-17-11 (2).docx	Form
CMS-10408 Final Survey CMS-10408.FINAL - Survey (11-28-11).pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 149.200

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10408	Yes	Yes	Fillable Fileable
Instruction		Yes	No	Printable Only
Instruction		Yes	No	Printable Only
Form	CMS-10408	Yes	Yes	Fillable Fileable
Other-CMS-10408 ERRP Survey_Email to Sponsors 11_17_11		Yes	No	Printable Only
Instruction		Yes	No	Printable Only
Form	CMS-10408	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Early Retiree Reinsurance Program

FR Citation: 75 FR 31440

Number of Respondents: 1,038

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,038	1,038
Annual IC Time Burden (Hours)	11,418	11,418
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.

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