(Cycle III) Annual Report

Reporting Requirements for Grants to States for Rate Review Cycle IV and Effective Rate Review Program (CMS-10380)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1121 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10380 (Cycle III) Annual Report Form and Instruction
CMS-10380 Cycle III - Annual Reporting Template Grant_Cycle_III_Annual_Report_Template-a.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	(Cycle III) Annual Report	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10380	Cycle III - Annual Reporting Template	Grant_Cycle_III_Annual_Report_Template-a.pdf		Yes	Yes	Fillable Fileable

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 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-56	56
Annual IC Time Burden (Hours)	-2,240	2,240
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.