Information Collection

Individual Screener

IC 206914 under ICR 201606-0938-009 · OMB 0938-1203.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10458 Individual Screener	Form and Instruction
CMS-10458 Individual Screener CMS-10458_Individual_Marketplace_Screener_(REVISED).pdf	Form and Instruction

IC Title:

Individual Screener

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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-10458	Individual Screener	CMS-10458_Individual_Marketplace_Screener_(REVISED).pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 33 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	30,000	30,000
Annual IC Time Burden (Hours)	940	940
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.