Information Collection

(Cycle III) Quarterly Report

IC 208091 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⚠️ Notice: This information collection may be referencing outdated material.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 III) Quarterly Report	Form and Instruction
CMS-10380 Cycle III - Quarterly Report Template Grant_Cycle_III_Quarterly_Report_Template-a.pdf	Form and Instruction

IC Title:

(Cycle III) Quarterly Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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 III - Quarterly Report Template	Grant_Cycle_III_Quarterly_Report_Template-a.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

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	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	224	224
Annual IC Time Burden (Hours)	5,824	5,824
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.