Survey of Plan Sponsors

Early Retiree Reinsurance Program: Survey of Plan Sponsors

Documents and Forms

Document Name Document Type
Form CMS-10408 Survey of Plan Sponsors Form and Instruction
CMS-10408 ERRP Survey CMS-10408_ERRP_Revised_Survey_Clean_FINAL.pdf Form and Instruction
CMS-10408 Revised_Survey_Screenshots CMS-10408_Revised_Survey_Screenshots.pdf Form and Instruction
CMS-10408_Subsequent_Email_Clean_Sponsor_Did_Not_Previously_Respond_FINAL.pdf CMS-10408_Subsequent_Email_Clean_Sponsor_Did_Not_Previously_Respond_FINAL IC Document
CMS-10408_Subsequent_Email_Clean_Sponsor_Previously_Responded_FINAL.pdf CMS-10408_Subsequent_Email_Clean_Sponsor_Previously_Responded_FINAL IC Document

Information Collection (IC) Details

IC Title:	Survey of Plan Sponsors	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 149.200

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10408	Revised_Survey_Screenshots	CMS-10408_Revised_Survey_Screenshots.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10408	ERRP Survey	CMS-10408_ERRP_Revised_Survey_Clean_FINAL.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 927	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: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	927	927
Annual IC Time Burden (Hours)	10,197	10,197
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10408_Subsequent_Email_Clean_Sponsor_Did_Not_Previously_Respond_FINAL	CMS-10408_Subsequent_Email_Clean_Sponsor_Did_Not_Previously_Respond_FINAL.pdf	01/25/2013
CMS-10408_Subsequent_Email_Clean_Sponsor_Previously_Responded_FINAL	CMS-10408_Subsequent_Email_Clean_Sponsor_Previously_Responded_FINAL.pdf	01/25/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.