Information Collection

States - Data Collection

IC 199275 under ICR 202510-0938-001 · OMB 0938-1086.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10320 State instructions and instruments States - Data Collection	Form and Instruction
CMS-10320 Appendix_E_State Requirements.pdf	Instruction
CMS-10320 State instructions and instruments CMS-10320.FINAL State Instructions and Instrument.pdf	Form and Instruction
CMS 10320 Appendix G_2020 .xlsm Data Collection Template	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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
Form and Instruction	CMS-10320				No		Paper Only
Instruction					Yes	No	Paper Only

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: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	-50	50
Annual IC Time Burden (Hours)	-400	400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Data Collection Template		01/28/2022

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

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