Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Application Unchanged 40 22560 28081 Form and Instruction CMS-10371 Revised FOA
Develpomental Phase Planning Review Unchanged 20 2220 0 Form and Instruction CMS-10371 Exchange Establishment Grant FOA
Operational Metrics - Monthly Reports Unchanged 96 2304 0 Form and Instruction CMS-10371 Exchange Establishment Grants FOA
Form and Instruction CMS-10371 Operational Metric – SBM Open Enrollment Weekly Indicators
Operational Metrics - Weekly Reports Modified 208 6240 0 Form and Instruction CMS-10371 Exchange Establishment Grant FOA
Form and Instruction CMS-10371 Cooperative Agreements to Support Establishment of State-Operated Health Insurance
Outcome Metrics - Annual Report Unchanged 16 640 0 Form and Instruction CMS-10371 Outcome Metrics - Annual Report
Form and Instruction CMS-10371 Outcome Metric – SBM Exchange Metrics
Performance Reviews Unchanged 16 3760 0 Form and Instruction CMS-10371 Revised FOA
Periodic Reporting Unchanged 48 11280 0 Form and Instruction CMS-10371 Revised FOA
Public Unchanged 160 1360 0 Form and Instruction CMS-10371 Revised FOA
Semi-Annual Reports Unchanged 80 9712 0 Form and Instruction CMS-10371 Establishment Grant FOA
Start-Up Year Establishment Review Unchanged 32 2752 0 Other-Data Elements
Start-up Outcomes Metrics - Quarterly Reports Unchanged 64 1152 0 Form and Instruction CMS-10371 Start-up Outcomes Metrics - Quarterly Reports
Form and Instruction CMS-10371 Outcome Metric – SBM Exchange Metrics
Work Plan Update Unchanged 80 160 0 Form and Instruction CMS-10371 Revised FOA
Total burden requested under this ICR: 860 64140 28081  
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