Information Collection

Survey Report Form Clinical Laboratory Improvement Amendments (CLIA) and supporting regulations in 42 CFR 493.1-493.2001

IC 8149 under ICR 200903-0938-011 · OMB 0938-0544.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0544 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-1557 Survey Report Form Clinical Laboratory Improvement Amendments (CLIA) and supporting regulations in 42 CFR 493.1-493.2001	Form and Instruction
CMS-1557 Survey Report Form (CLIA) CMS1557.pdf www.cms.hhs.gov/forms/	Form and Instruction

IC Title:

Survey Report Form Clinical Laboratory Improvement Amendments (CLIA) and supporting regulations in 42 CFR 493.1-493.2001

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 493.1-493.2001

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
Form and Instruction	CMS-1557	Survey Report Form (CLIA)	CMS1557.pdf	http://www.cms.hhs.gov/forms/	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 21,000

Number of Respondents for Small Entity: 8,426

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
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10,500	-2,000	12,500
Annual IC Time Burden (Hours)	5,248	-1,002	6,250
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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