Information Collection

Survey of Plan Sponsors

IC 205535 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 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

IC Title:

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:

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-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 %

table that charts list of burden
	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

table that charts IC Documents
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.