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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.