Start-up Outcomes Metrics - Quarterly Reports

Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1119 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10371 Start-up Outcomes Metrics - Quarterly Reports Form and Instruction
CMS-10371 Start-up Outcomes Metrics - Quarterly Reports CMS-10371 - Data Elements Start up Outcomes Metrics Quarter_508 pdf - Adobe Acrobat Pro.pdf Form and Instruction
CMS-10371 Outcome Metric – SBM Exchange Metrics 0938-1119. (Outcome Metric) SBM Exchange Metrics 20130829 pg layout.xlsx Form and Instruction

Information Collection (IC) Details

IC Title:	Start-up Outcomes Metrics - Quarterly Reports	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10371	Outcome Metric – SBM Exchange Metrics	0938-1119. (Outcome Metric) SBM Exchange Metrics 20130829 pg layout.xlsx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10371	Start-up Outcomes Metrics - Quarterly Reports	CMS-10371 - Data Elements Start up Outcomes Metrics Quarter_508 pdf - Adobe Acrobat Pro.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 16	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	64	64
Annual IC Time Burden (Hours)	1,152	1,152
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.