Information Collection

(Cycle III) Transaction Data Collection

IC 208092 under ICR 201408-0938-009 · 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⚠️ Notice: This information collection may be referencing outdated material.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) Transaction Data Collection	Form and Instruction
CMS-10380 Cycle III - Data CMS-10380 - Rate Review Grant Program Data Dictionary_0713.pdf	Form and Instruction

IC Title:

(Cycle III) Transaction Data Collection

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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 - Data	CMS-10380 - Rate Review Grant Program Data Dictionary_0713.pdf		Yes	Yes	Paper Only

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: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-280	280
Annual IC Time Burden (Hours)	-8,400	8,400
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.