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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
#19: Eligibility and Enrollment Performance Indicators
Agency IC Tracking Number:
IC Status:
New
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
Form
CMS-10398 (#19)
Monthly Report
_ 19 - MonthlyReportForm-State.pdf
Yes
Yes
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
51
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
100 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
612
0
612
0
0
0
Annual IC Time Burden (Hours)
12,240
0
12,240
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
#19 Supporting Statement: Eligibility and Enrollment Performance Indicators
#19 Supporting Statement Eligibility and Enrollment Performace Indicators [Dec 2014].docx
12/23/2014
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.