Information Collection

GenIC #62 (New): Data Collection for Section 1003 of the SUPPORT Act

IC 241052 under ICR 201712-0938-019 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
62 - Sec1003QtrlyInstructions (2020 version 5) Final.docx	Instruction
CMS-10398 #62 Quarterly Progress Report (QPR) Template 62 - Sec1003QtrlyReportForm20200221-4.xlsx	Form
62 - Generic Supporting Statement (2020 version 4).docx Generic Supporting Statement	IC Document

IC Title:

GenIC #62 (New): Data Collection for Section 1003 of the SUPPORT Act

Agency IC Tracking Number:

CMCS

IC Status: New

Obligation to Respond: Mandatory

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
Instruction			62 - Sec1003QtrlyInstructions (2020 version 5) Final.docx		No		Printable Only
Form	CMS-10398 #62	Quarterly Progress Report (QPR) Template	62 - Sec1003QtrlyReportForm20200221-4.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	60	60
Annual IC Time Burden (Hours)	840	840
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement	62 - Generic Supporting Statement (2020 version 4).docx	04/03/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.