Information Collection

Non-Statistical Data - Federal Government

IC 192613 under ICR 201004-0938-004 · OMB 0938-1015.

Documents and Forms

Document Name Document Type
Form CMS-10197 Non-Statistical Data - Federal Government Form and Instruction
CMS-10197 CMS-10197 AppendixC-NonstatisticalInstruments11_6_508rea CMS-10197 AppendixC-NonstatisticalInstruments11_6_508ready.pdf Form and Instruction
CMS-10197 CMS-10197 AppendixD-InfConsentFormsScripts11 CMS-10197 AppendixD-InfConsentFormsScripts11_6_508ready.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Non-Statistical Data - Federal Government	Agency IC Tracking Number:

Is this a Common Form? No		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 and Instruction	CMS-10197	CMS-10197 AppendixC-NonstatisticalInstruments11_6_508ready	CMS-10197 AppendixC-NonstatisticalInstruments11_6_508ready.pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-10197	CMS-10197 AppendixD-InfConsentFormsScripts11	CMS-10197 AppendixD-InfConsentFormsScripts11_6_508ready.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Master Demonstration, Evaluation and Research Studies for ORDI	FR Citation: 72 FR 19705

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.