Information Collection

State Based Marketplace Data Collection Templates for Bi-Annual Reporting

IC 252604 under ICR 202506-0938-001 · OMB 0938-1119.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1119 can be found here:

Documents and Forms

Document Name Document Type
CMS-10371 - Cooperative Agreement Bi-Annual Metrics 30-day Final.docx Other-Data Template
CMS-10371 - Cooperative Agreement Bi-Annual Metrics 30-day Final.docx Other-Data Template

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State Based Marketplace Data Collection Templates for Bi-Annual Reporting	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Data Template			CMS-10371 - Cooperative Agreement Bi-Annual Metrics 30-day Final.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	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 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	40	4	36
Annual IC Time Burden (Hours)	492	123	369
Annual IC Cost Burden (Dollars)	0	-1,251,236	1,251,236

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.

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