Information Collection

Administrative Cost Forms for MIPCD

IC 213346 under ICR 201410-0938-001 · OMB 0938-1219.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10477 Administrative Cost Forms for MIPCD	Form and Instruction
CMS-10477 Combined Administrative Cost Form - Informed Consent Attachment_10a_CombinedAdminCostsForm.pdf	Form and Instruction
CMS-10477 Yearly Admin Cost Form Attachment_10b_YearlyAdminCostsForm.pdf	Form and Instruction
Attachment_10c_AdminCostsFormEmailScr.pdf Admin cost Form Email Script	IC Document
Attachment_10d_AdminCostFormEmailAnn.pdf Admin Cost Form Email Solicitation - Script Annual	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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-10477	Combined Administrative Cost Form - Informed Consent	Attachment_10a_CombinedAdminCostsForm.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10477	Yearly Admin Cost Form	Attachment_10b_YearlyAdminCostsForm.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	400	400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Admin cost Form Email Script	Attachment_10c_AdminCostsFormEmailScr.pdf	10/01/2014
Admin Cost Form Email Solicitation - Script Annual	Attachment_10d_AdminCostFormEmailAnn.pdf	10/01/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.