Information Collection

Enhanced Reporting (Before Loan Repayment) - Start-up/Solvency Loan Recipients

IC 198655 under ICR 201504-0938-015 · OMB 0938-1139.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10392 Enhanced Reporting (Before Loan Repayment) - Start-up/Solvency Loan Recipients	Form and Instruction
CMS-10392 Reporting Templates CMS-10392.CO-OP Reporting Template.docx	Form and Instruction
CMS-10392 CO-OP FOA CMS-10392_CO-OP_FOA_(final).pdf	Form and Instruction
CMS-10392 Monthly Reporting Guidance CMS-10392 - Monthly Reporting Guidance 04012015 FINAL.PDF	Form and Instruction
CMS-10392 Monthly Reporting Template CMS-10392 - Monthly reporting template 04012015 FINAL.pdf - Adobe Acro....pdf	Form and Instruction
CMS-10392 Semi-Annual Reporting Template CMS-10392 - Semi-Annual Report.accdb	Form and Instruction
CMS-10392 Quarterly Financial Report CMS-10392 - CO-OP Program Quarterly Financial Report Access Database 9-21-12 (2).mpp	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 156

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-10392	Reporting Templates	CMS-10392.CO-OP Reporting Template.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10392	CO-OP FOA	CMS-10392_CO-OP_FOA_(final).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10392	Monthly Reporting Guidance	CMS-10392 - Monthly Reporting Guidance 04012015 FINAL.PDF	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10392	Monthly Reporting Template	CMS-10392 - Monthly reporting template 04012015 FINAL.pdf - Adobe Acro....pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10392	Semi-Annual Reporting Template	CMS-10392 - Semi-Annual Report.accdb	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10392	Quarterly Financial Report	CMS-10392 - CO-OP Program Quarterly Financial Report Access Database 9-21-12 (2).mpp	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 10

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 98 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	60	60
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.