Information Collection

FSR 237 HHS CMS Palmetto GBA J1 MAC

IC 186862 under ICR 200707-1505-002 · OMB 1505-0186.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1505-0186 can be found here:

Documents and Forms

Document Name Document Type
Form FSR 237 FSR 237 HHS CMS Palmetto GBA J1 MAC Form
FSR 237 HHS CMS Palmetto GBA J1 MAC questionnaire FSR 237 HHS CMS Palmetto GBA J1 MAC.xls Form
Justification for FSR 237.doc updated supporting statement IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	FSR 237 HHS CMS Palmetto GBA J1 MAC	Agency IC Tracking Number:	FSR 237

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	FSR 237	HHS CMS Palmetto GBA J1 MAC questionnaire	FSR 237 HHS CMS Palmetto GBA J1 MAC.xls		Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	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	5,000	0	0	0	0	0
Annual IC Time Burden (Hours)	208	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
updated supporting statement	Justification for FSR 237.doc	10/30/2008

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.