OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Health Equity award Nominations

IC 263665 under ICR 202311-0938-010 · OMB 0938-1457.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Health Equity award Nominations
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10866 CMS Health Equity Nomination Form CMSHealthEquityNominationForm_Clean.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10866 CMS Health Equity Scoring Rubric CMS Health Equity Award 2020_scoring rubric and worksheet_Clean.pdf Yes Yes Fillable Printable

Health Health Care Services

 

50 0
   
Federal Government
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 50 0 0 0 50 0
Annual IC Time Burden (Hours) 100 0 0 0 100 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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