Information Collection

Disclosure of Financial Relationships Report ("DFRR") - Section 5006 of the DRA-CMS 10236

IC 37931 under ICR 200710-0938-003 · OMB 0938-0995.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10236 Disclosure of Financial Relationship Report (DFRR)-Revised 8-31-07.xls	Other-Report
CMS-10236 Attachment 1 - Instructions for Disclosure of Financial Relationship Report (DFRR) Revised83110am.doc	Instruction
CMS-10236 coverletter to 500 hospitals -- 8-30-07 3pm.doc CMS-10236 coverletter to 500 hospitals -- 8-30-07 3pm	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 411.361

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Report			CMS-10236 Disclosure of Financial Relationship Report (DFRR)-Revised 8-31-07.xls		Yes	Yes	Paper Only
Instruction			CMS-10236 Attachment 1 - Instructions for Disclosure of Financial Relationship Report (DFRR) Revised83110am.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	3,000	3,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10236 coverletter to 500 hospitals -- 8-30-07 3pm	CMS-10236 coverletter to 500 hospitals -- 8-30-07 3pm.doc	10/04/2007

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