Information Collection

Data Collection Report (Initial Submission)

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10333 Appendix 1 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

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:

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-10333				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 %

table that charts list of burden
	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

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.

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