Annual Report

Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges (CMS-10371)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1119 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10371 Annual Report Form and Instruction
CMS-10371 Annual Report Template CMS-10371 - Progress_Report_Instrument.pdf Form and Instruction
CMS-10371 Annual Reporting Data Elements CMS-10371 - Progress_Report-Data_Elements.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Annual Report	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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-10371	Annual Report Template	CMS-10371 - Progress_Report_Instrument.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10371	Annual Reporting Data Elements	CMS-10371 - Progress_Report-Data_Elements.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 18	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	18	2	16
Annual IC Time Burden (Hours)	540	-100	640
Annual IC Cost Burden (Dollars)	0	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.