Information Collection

State Based Marketplace Data Collection Templates for Bi-Annual Reporting

IC 252604 under ICR 202604-0938-015 · OMB 0938-1119.

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: Unchanged

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	Previously Approved
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	492	492
Annual IC Cost Burden (Dollars)	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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