Information Collection

Survey of Retail Prices

IC 201423 under ICR 202512-0938-013 · OMB 0938-1041.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10241 Survey of Retail Prices	Form and Instruction
Form CMS-10241 Survey of Retail Prices (English) Survey of Retail Prices	Form and Instruction
Form CMS-10241 Survey of Retail Prices (Spanish) Survey of Retail Prices	Form and Instruction
CMS-10241 Survey of Retail Prices (English) 2025_NADAC Survey Tool - CLEAN Version.docx	Form and Instruction
CMS-10241 Survey of Retail Prices (English) 2025_NADAC Survey Tool - CLEAN Version.docx	Form and Instruction
CMS-10241 Survey of Retail Prices (Spanish) 2025_NADAC Notificacion de Encuesta e Instrucciones_CLEAN.docx	Form and Instruction
CMS-10241 Survey of Retail Prices (Spanish) 2025_NADAC Notificacion de Encuesta e Instrucciones_CLEAN.docx	Form and Instruction
2025_NADAC Survey Tool - REDLINE Version.docx REDLINE - Survey (English)	IC Document
2025_NADAC Survey Tool - REDLINE Version.docx REDLINE - Survey (English)	IC Document
2025_NADAC Notificacion de Encuesta e Instrucciones_REDLINE.docx REDLINE - Survey (Spanish)	IC Document
2025_NADAC Notificacion de Encuesta e Instrucciones_REDLINE.docx REDLINE - Survey (Spanish)	IC Document
CMS-10241 - Crosswalk of Nonsubstantive Changes.xlsx CROSSWALK - Survey	IC Document
CMS-10241 - Crosswalk of Nonsubstantive Changes.xlsx CROSSWALK - Survey	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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-10241				Yes	Yes	Fillable Printable
Form and Instruction	CMS-10241				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 72,000

Number of Respondents for Small Entity: 21,024

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 70 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	72,000	72,000
Annual IC Time Burden (Hours)	36,000	36,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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

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