Information Collection

Data Collection Report (Initial Submission)

IC 193767 under ICR 201611-0938-003 · OMB 0938-1097.

Documents and Forms

Document Name Document Type
Form CMS-10333 Data Collection Report (Initial Submission) Form and Instruction
CMS-10333 Appendix 1 CMS-10333 Appendix 1_Screenshots of CCIIO-Developed Databasewdis.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Data Collection Report (Initial Submission)	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-10333	Appendix 1	CMS-10333 Appendix 1_Screenshots of CCIIO-Developed Databasewdis.pdf		No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	51	-5	56
Annual IC Time Burden (Hours)	2,295	727	1,568
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.