View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 0938-1177	ICR Reference No: 202310-0938-005
Status: Active	Previous ICR Reference No: 202010-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Beneficiary and Family Centered Data Collection (CMS-10393)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/08/2024
	Date Received in OIRA: 10/30/2023
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2027	36 Months From Approved	08/31/2024
Responses	9,000	0	8,700
Time Burden (Hours)	2,250	0	2,175
Cost Burden (Dollars)	31,365	0	30,320

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	9,000	8,700	300
Annual Time Burden (Hours)	2,250	2,175	75
Annual Cost Burden (Dollars)	31,365	30,320	1,045

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The total estimated burden for this request will increase by 75 hours (2,175 to 2,250) due to changes in the total universe volumes.

Annual Cost to Federal Government: $3,100,802

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Denise King 410 786-1013 Denise.King@cms.hhs.gov

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