Clinical Laboratory Improvement Amendments Application Form

ICR 199609-0938-001

OMB: 0938-0581

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0581 199609-0938-001
Historical Active 199502-0938-006
HHS/CMS
Clinical Laboratory Improvement Amendments Application Form
Extension without change of a currently approved collection   No
Regular
Approved without change 11/04/1996
Retrieve Notice of Action (NOA) 09/04/1996
Approved for use through 11/98 under the conditions identical to OMB's clearance remarks dated 5/23/95. In addition, HCFA must immediately incorporate the disclosure statements mandated by the Paperwork Reduction Act of 1995. HCFA must submit to OMB the revised forms/instructions for the public record.
  Inventory as of this Action Requested Previously Approved
11/30/1998 11/30/1998 12/31/1996
16,000 0 16,000
20,000 0 440,000
0 0 0

The application must be completed by entities performing laboratory testing on human specimens for health purposes. This information is vital to the certification process.

None
None


No

1
IC Title Form No. Form Name
Clinical Laboratory Improvement Amendments Application Form HCFA-116

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 16,000 16,000 0 0 0 0
Annual Time Burden (Hours) 20,000 440,000 0 -420,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
09/04/1996


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