Information Collection

(Cycle I) Final Report

IC 198639 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⚠️ Notice: This information collection may be referencing outdated material.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) Final Report	Form and Instruction
CMS-10380 Cycle I FOA grant to states for health insurance premium review - cycle 1.doc	Form and Instruction
CMS-10380 Cycle 1 - Final report template Grant Cycle I Final Report Template.pdf	Form and Instruction

IC Title:

(Cycle I) Final Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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 FOA	grant to states for health insurance premium review - cycle 1.doc		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10380	Cycle 1 - Final report template	Grant Cycle I Final Report Template.pdf		Yes	Yes	Fillable Fileable

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	Previously Approved
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	2,040	2,040
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.