Form CMS-855S

PAPERWORK REDUCTION ACT SUBMISSION WORKSHEET

Part II: Information Collection Detail

This template is intended for staff without an ICRAS account. Please fill out and submit to the appropriate Operating Division to enter into ICRAS. The form mirrors the screens available in the ICRAS 4 system. To request an account to log into ICRAS.

Instructions for filling out the form are available at www.paperworkreduction.gov.

1. Title: Medicare Durable Medical Equipment Supplier Enrollment Application - CMS 855S

(Surety Bond - §424.57(d)(6)

2. Is this a Common Form?

3. Obligation to respond (check one)

4. Frequency of reporting (check all that apply)

Yes

X No

a. Voluntary

b. X Required to obtain or retain benefits

c. Mandatory

a. Hourly (24 -7)

b. __Hourly Bus (40 per week)

c. Daily (7 per week)

d. Daily Bus (5 per week)

e. Weekly (52 per year)

f. Monthly

g. Yearly

h. Every Decade

i. Quarterly

j. Semi-annually

k. Biennially

l.___ Once

m. _X_ occasionally

5. CFR Citation(s) for the information collection under review (if applicable).
   
   

Title __42_ Part __424______________ Section_____57(d)(6) ____________

Title __ _ Part ________________ Section_____ ____________

Title _______ Part __________________ Section________________________

Title _______ Part __________________ Section________________________

6. Information Collection Instruments – Send all instruments along with the Part 2 form(s). If more than one Part 2 is completed make sure to identify which instruments are associated with which Part 2 form.

7. Federal Enterprise Architecture Business Reference Model (Select one Services for Citizens Line of Business and one Subfunction from its group)

Services for Citizens Line of Business	Subfunction
None
Community and Social Services___	Homeownership Promotion___ Community and Regional Development___ Social Services___ Postal Service___ None___
Correctional Activities___	Criminal Incarceration Criminal Rehabilitation None
Defense and National Security___	Strategic National and Theater Defense___ Operational Defense___ Tactical Defense___ None___
Disaster Management___	Disaster Monitoring and Predication___ Disaster Preparedness and Planning___ Disaster Repair and Restore___ Emergency Response___ None___
Economic Development___	Business and Industry Development___ Intellectual Property Protection___ Financial Sector Oversight___ Industry Sector Income Stabilization___ None___
Education___	Elementary, Secondary, and Vocational Education___ Higher Education___ Cultural and Historic Preservation___ Cultural and Historic Exhibition___ None___
Energy___	Energy Supply___ Energy Conservation and Preparedness___ Energy Resource Management___ Energy Production___ None___
Environmental Management___	Environmental Monitoring and Forecasting___ Environmental Remediation___ Pollution Prevention and Control___ None___
General Science and Innovation___	Scientific and Technological Research and Innovation___ Space Exploration and Innovation ___ None___
Health _X_	Illness Prevention___ Immunization Management___ Public Health Monitoring___ Health Care Services _X_ Consumer Health and Safety___ None___
Homeland Security___	Border and Transportation Security___ Key Asset and Critical Infrastructure Protection___ Catastrophic Defense___ None___
Income Security___	General Retirement and Disability___ Unemployment Compensation___ Housing Assistance___ Food and Nutrition Assistance___ Survivor Compensation___ None___
Intelligence Operations___	Intelligence Planning and Direction/Needs___ Intelligence Collection___ Intelligence Analysis and Production___ Dissemination___ None___
International Affairs and Commerce___	Foreign Affairs___ International Development and Humanitarian Aid___ Global Trade___ None___
Law Enforcement___	Criminal Apprehension___ Criminal Investigation and Surveillance___ Citizen Protection___ Crime Prevention___ Leadership Protection___ Property Protection___ Substance Control___ None___
Litigation and Judicial Activities___	Judicial Hearing___ Legal Defense___ Legal Investigation___ Legal Prosecution and Litigation___ Resolution Facilitation ___ None___
Natural Resources___	Water Resource Management___ Conservation, Marine and Land Management___ Recreational Resource Management and Tourism___ Agricultural Innovation and Services___ None___
Transportation___	Air Transportation___ Ground Transportation___ Water Transportation___ Space Operations___ None___
Workforce Management___	Training and Employment___ Labor Rights Management___ Worker Safety___ None___

See http://www.feapmo.gov for the Business Reference Model categories and definitions.

8. Privacy Act System of Records (if applicable) n/a

Title:

Federal Register Citation: Volume ________ Page number ____________ Publication date / /____

9. Respondents

a. Total # 250

b. Small Entity # _________

c. Percent Electronic __0__________

Affected public (choose one)
a. Individuals or households

b. X Private Sector
c. State, Local, or Tribal Governments
d. Federal Government

(if Private Sector check all that apply)
a. X Business or other for-profits
b. X Not-for-profit institutions
c. Farms

10. Frequency: How often on average will each respondent respond to the Information Collection?

Number of Responses per Respondent __1________

Per (select the most appropriate time period for this collection)

a. Hour (24-7) - 8736 per year

b. Business Hour (40 per week) - 2080 per year

c. Day (7 per week) - 364 per year

d. Business Day (5 per week) - 260 per year

e. Week - 52 per year

f. Month - 12 per year

g. X Year

h. Decade .1 per year

i. Quarter - 4 per year

j. Half-Year - 2 per year

k. Biennial - 0.5 per year

Calculated: Annual Frequency =____1________times a year (per respondent)

Calculated: Annual Number Of Responses = _____250____ a year

11. Hour and Cost Burden Enter the hours and cost (per response) broken out by reporting, record keeping, and third-party disclosure.
	Time per Response	Hour per response	Annual Hour Burden	Cost per Response	Annual cost Burden
Reporting	3 hours	3 hours	750 hours
Record keeping
Third party disclosure
Total

12. Allocate the change in burden

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses
b. Annual Hour Burden	hours	hours	hours	hours	hours	hours
c. Annual Cost Burden	$	$	$	$	$	$