Information Collection

Data Collection Report (Quarterly and Annual Reports)

IC 193768 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 Data Collection Report (Quarterly and Annual Reports)	Form and Instruction
CMS-10333 Appendix 3 CMS-10333 Appendix 3_Template for the Annual Report.pdf	Form and Instruction
CMS-10333 Appendix 2 CMS-10333 Appendix 2_Template for the Quarterly Progress Reportis.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	Appendix 3	CMS-10333 Appendix 3_Template for the Annual Report.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10333	Appendix 2	CMS-10333 Appendix 2_Template for the Quarterly Progress Reportis.pdf		Yes	Yes	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	408	-96	504
Annual IC Time Burden (Hours)	9,588	-5,028	14,616
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.