Information Collection

Title Disclosure of Financial Relationships Report (DFRR) - (CMS-10236)

IC 182211 under ICR 200901-0938-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10236 Attachment 1 - Instructions for DFRR Revised 12.08.doc	Instruction
CMS-10236 Disclosure of Financial Relationships Report ("DFRR") Disclosure of Financial Relationship Report (DFRR)-Revised 12.08.xls	Form
CMS-10236 Summary of Changes to DFRR 12.08.doc CMS-10236 Summary of Changes to DFRR 12	IC Document
CMS-10236 coverletter to 400 hospitals -12.08.doc CMS-10236 coverletter to 400 hospitals -12	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
Instruction			CMS-10236 Attachment 1 - Instructions for DFRR Revised 12.08.doc		Yes	Yes	Paper Only
Form	CMS-10236	Disclosure of Financial Relationships Report ("DFRR")	Disclosure of Financial Relationship Report (DFRR)-Revised 12.08.xls		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 400

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	400	400
Annual IC Time Burden (Hours)	40,000	40,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10236 Summary of Changes to DFRR 12	CMS-10236 Summary of Changes to DFRR 12.08.doc	12/16/2008
CMS-10236 coverletter to 400 hospitals -12	CMS-10236 coverletter to 400 hospitals -12.08.doc	12/16/2008

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