Information Collection

Support of State Readiness Review (POs)

IC 223822 under ICR 201610-0938-001 · OMB 0938-1326.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1326 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10631 Support of State Readiness Review (POs)	Form and Instruction
CMS-10631 PACE Application PACE Paper Application [rev 10-05-2016 by OSORA PRA].pdf	Form and Instruction

IC Title:

Support of State Readiness Review (POs)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 460.12(b)(1)

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-10631	PACE Application	PACE Paper Application [rev 10-05-2016 by OSORA PRA].pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 22

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	22	22
Annual IC Time Burden (Hours)	1,056	1,056
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.