Information Collection

Survey of Retail Prices

IC 201423 under ICR 202611-0938-018 · OMB 0938-1041.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
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 (Spanish) 2025_NADAC Notificacion de Encuesta e Instrucciones_CLEAN.docx	Form and Instruction

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: 18,960

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	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

table that charts IC Documents
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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