Information Collection

Self-Insured Non-Federal Governmental Plans (NQTL analysis)

IC 246609 under ICR 202409-0938-011 · OMB 0938-1393.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10773 Appendix I - FAQs-Part-45.docx	Other-Guidance
CMS-10773 Appendix I - FAQs-Part-45.docx	Other-Guidance

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Other-Guidance					Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 33,076

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	33,076	-1,803	34,879
Annual IC Time Burden (Hours)	882,027	-48,080	930,107
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.

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