View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 0938-1471	ICR Reference No: 202403-0938-016
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: OIT
Title: ADA Dental Claim Form (CMS-10883)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR: Yes
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/30/2024
	Date Received in OIRA: 04/04/2024
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2027	36 Months From Approved
Responses	360,000	0	0
Time Burden (Hours)	17,667	0	0
Cost Burden (Dollars)	44,000	0	0

ICR Summary of Burden

	Total Approved	Change Due to New Statute
Annual Number of Responses	360,000	360,000
Annual Time Burden (Hours)	17,667	17,667
Annual Cost Burden (Dollars)	44,000	44,000

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: This is a new information collection request.

Annual Cost to Federal Government: $2,584

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. Yes

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: Malcolm Wilson 667 414-0087 malcolm.wilson@cms.hhs.gov

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