Information Collection

Bundle: #7 (CHIPRA Cycle III and IV) and #41 (1095 B Reporting)

IC 217381 under ICR 201410-0938-016 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10398 (#7) Bundle: #7 (CHIPRA Cycle III and IV) and #41 (1095 B Reporting) Form and Instruction
CMS-10398 (#7) Cycle III Semi-Annual Report Template 7 CHIPRA Cycle III reporting template Final [rev 04-15-2015 by OSORA PRA].doc Form and Instruction
CMS-10398 (#7) Cycle IV Semi-Annual Report Template 7 CHIPRA Cycle IV Template.docx Form and Instruction
CMS-10398 (#7) Cycle III Final Report Addendum Cycle III Final Report Template due 10 13 15 kf+mr (7).doc Form and Instruction
CMS-10398 (#41) 1095 B Reporting (Conf Call Questions) 1095 B Reporting [rev 07-09-2015 by OSORA PRA].docx Form
41 - Supporting Statement [rev 07-09-2015 by OSORA PRA].docx 41 - Supporting Statement IC Document
Bundled Burden Table (07-09-2015 submission).xlsx Bundled Burden Summary Table IC Document
7 - Supporting Statement [rev 07-09-2015 by OSORA PRA].doc 7 - Supporting Statement IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Bundle: #7 (CHIPRA Cycle III and IV) and #41 (1095 B Reporting)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10398 (#7)	Cycle III Semi-Annual Report Template	7 CHIPRA Cycle III reporting template Final [rev 04-15-2015 by OSORA PRA].doc	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10398 (#7)	Cycle IV Semi-Annual Report Template	7 CHIPRA Cycle IV Template.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10398 (#7)	Cycle III Final Report Addendum	Cycle III Final Report Template due 10 13 15 kf+mr (7).doc	Yes	Yes	Fillable Printable
Form	CMS-10398 (#41)	1095 B Reporting (Conf Call Questions)	1095 B Reporting [rev 07-09-2015 by OSORA PRA].docx	No		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: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	97	97
Annual IC Time Burden (Hours)	138	138
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
41 - Supporting Statement	41 - Supporting Statement [rev 07-09-2015 by OSORA PRA].docx	07/09/2015
Bundled Burden Summary Table	Bundled Burden Table (07-09-2015 submission).xlsx	07/09/2015
7 - Supporting Statement	7 - Supporting Statement [rev 07-09-2015 by OSORA PRA].doc	07/09/2015

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