Information Collection

States: SBE's, Federal Platform and Partnership States

IC 206071 under ICR 202604-0938-001 · OMB 0938-1187.

Documents and Forms

Document Name Document Type
Form CMS-10433 Interoperability Web Form States: SBE's, Federal Platform and Partnership States Form
CMS-10433 Interoperability Web Form J_Interoperability_Web_Form_508.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	States: SBE's, Federal Platform and Partnership States	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 155.705

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10433	Interoperability Web Form	J_Interoperability_Web_Form_508.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	3	-37	40
Annual IC Time Burden (Hours)	30	-90	120
Annual IC Cost Burden (Dollars)	0	0	0

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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