Information Collection

Administrative Data Report (CMS-368)

IC 8197 under ICR 201407-0938-012 · OMB 0938-0582.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0582 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-368 Administrative Data Report (CMS-368)	Form
CMS-368 Disclosure Statement_2014.doc	Other-PRA Disclosure Statement
CMS-368 Medicaid Drug Rebate Program, State Agency Contact Form CMS Form 368_2014.pdf	Form

IC Title:

Administrative Data Report (CMS-368)

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	CMS-368	Medicaid Drug Rebate Program, State Agency Contact Form	CMS Form 368_2014.pdf		Yes	Yes	Fillable Printable
Other-PRA Disclosure Statement			CMS-368 Disclosure Statement_2014.doc		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

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	Previously Approved
Annual Number of Responses for this IC	10	-214	224
Annual IC Time Burden (Hours)	5	-12,096	12,101
Annual IC Cost Burden (Dollars)	0	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.