Information Collection

(Cycle I) Quarterly Reports

IC 196340 under ICR 201308-0938-004 · OMB 0938-1121.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1121 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10380 (Cycle I) Quarterly Reports	Form and Instruction
CMS-10380 Cycle I - Quarterly Report Grant Cycle I Quarterly Report Template.pdf	Form and Instruction

IC Title:

(Cycle I) Quarterly Reports

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-10380	Cycle I - Quarterly Report	Grant Cycle I Quarterly Report Template.pdf		No	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	20	-184	204
Annual IC Time Burden (Hours)	480	-4,416	4,896
Annual IC Cost Burden (Dollars)	0	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.