State Health Insurance Exchange Security Incident Report

ICR 201403-0938-002

OMB: 0938-1216

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2014-03-06
IC Document Collections
IC ID
Document
Title
Status
208397 Modified
ICR Details
0938-1216 201403-0938-002
Historical Active 201308-0938-026
HHS/CMS 21546
State Health Insurance Exchange Security Incident Report
Extension without change of a currently approved collection   No
Regular
Approved without change 04/21/2014
Retrieve Notice of Action (NOA) 03/06/2014
  Inventory as of this Action Requested Previously Approved
04/30/2017 36 Months From Approved 04/30/2014
936 0 936
234 0 234
0 0 0

As part of the privacy and security oversight of State Health Insurance Exchanges the States will be required to report security incidents include breaches of personally identifiable information (PII). This reporting will be made by completing and electronically submitting the State Health Insurance Exchange Security Incident Report (Incident Report), or providing identical information telephonically.

PL: Pub.L. 111 - 148 Title1 Name of Law: Affordable Care Act
  
None

Not associated with rulemaking

  78 FR 77135 12/20/2013
79 FR 11435 02/28/2014
No

1
IC Title Form No. Form Name
Incident Reporting CMS-10496 STATE HEALTH INSURANCE EXCHANGE SECURITY INCIDENT REPORT

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 936 936 0 0 0 0
Annual Time Burden (Hours) 234 234 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$502
No
No
Yes
No
No
Uncollected
William Parham 4107864669

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
03/06/2014


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