Survey of Plan Sponsors (Private Entities)

Early Retiree Reinsurance Program: Survey of Plan Sponsors

Documents and Forms

Document Name Document Type
Form CMS-10408 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

Information Collection (IC) Details

IC Title:	Survey of Plan Sponsors (Private Entities)	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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10408	ERRP Survey of Plan Sponsors	CMS 10408_ERRP Survey of Plan Sponsors_508.pdf	Yes	Yes	Fillable Fileable
Instruction			CMS 10408_ERRP Survey of Plan Sponsors_Instructions_508.pdf	Yes	No	Printable Only
Instruction			CMS-10408.Final Draft Survey Instructions (11-23-11).pdf	Yes	No	Printable Only
Form	CMS-10408	Final Survey	CMS-10408.FINAL - Survey (11-28-11).pdf	Yes	No	Fillable Printable
Instruction			CMS-10408 REVISED _ ERRP Survey of Plan Sponsors _ Instructions 11-17-11.docx	Yes	No	Printable Only
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	Yes	Yes	Fillable Fileable
Other-CMS-10408 ERRP Survey_Email to Sponsors 11_17_11			CMS-10408 ERRP Survey_Email to Sponsors 11_17_11_FINAL.docx	Yes	No	Printable Only

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 %

	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

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.