Information Collection

Health Equity award Nominations

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10866 Health Equity award Nominations	Form and Instruction
CMS-10866 CMS Health Equity Nomination Form CMSHealthEquityNominationForm_Clean.pdf	Form and Instruction
CMS-10866 CMS Health Equity Nomination Form CMSHealthEquityNominationForm_Clean.pdf	Form and Instruction
CMS-10866 CMS Health Equity Scoring Rubric CMS Health Equity Award 2020_scoring rubric and worksheet_Clean.pdf	Form and Instruction
CMS-10866 CMS Health Equity Scoring Rubric CMS Health Equity Award 2020_scoring rubric and worksheet_Clean.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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-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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	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.