Survey of Retail Prices

[Medicaid] Survey of Retail Prices (CMS-10241)

OMB: 0938-1041

IC ID: 201423

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Survey of Retail Prices
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10241 Survey of Retail Prices (English) 2025_NADAC Survey Tool - CLEAN Version.docx Yes Yes Fillable Printable
Form and Instruction CMS-10241 Survey of Retail Prices (Spanish) 2025_NADAC Notificacion de Encuesta e Instrucciones_CLEAN.docx Yes Yes Fillable Fileable

Health Health Care Services

 

72,000 21,024
   
Private Sector Businesses or other for-profits
 
   70 %

  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 72,000 0 0 0 0 72,000
Annual IC Time Burden (Hours) 36,000 0 0 0 0 36,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
REDLINE - Survey (English) 2025_NADAC Survey Tool - REDLINE Version.docx 12/10/2025
REDLINE - Survey (Spanish) 2025_NADAC Notificacion de Encuesta e Instrucciones_REDLINE.docx 12/10/2025
CROSSWALK - Survey CMS-10241 - Crosswalk of Nonsubstantive Changes.xlsx 12/10/2025
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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