Information Collection

States - Data Collection

IC 199275 under ICR 201404-0938-002 · OMB 0938-1086.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1086 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10320 States - Data Collection Form and Instruction
CMS-10320 Appendix E - State Requirements CMS-10320 - Appendix_E_StateRequirements.pdf Form and Instruction
CMS-10320 State Instructions and Application CMS-10320.FINAL State Instructions and Instrument (5-5-10).pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	States - Data Collection	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

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-10320	Appendix E - State Requirements	CMS-10320 - Appendix_E_StateRequirements.pdf		Yes	No	Paper Only
Form and Instruction	CMS-10320	State Instructions and Application	CMS-10320.FINAL State Instructions and Instrument (5-5-10).pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	400	400
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.