Transaction Data Collection

Reporting Requirements for Grants to States for Rate Review Cycle IV and Effective Rate Review Program (CMS-10380)

Documents and Forms

Document Name Document Type
Form CMS-10380 Transaction Data Collection Form
CMS-10380 Grant Program Data Dictionary CMS-10380_Grant_Program_Data_Dictionary_.pdf Form

Information Collection (IC) Details

IC Title:	Transaction Data Collection	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 154.301

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10380	Grant Program Data Dictionary	CMS-10380_Grant_Program_Data_Dictionary_.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 18	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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	90	-120	210
Annual IC Time Burden (Hours)	6,300	0	6,300
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.