Information Collection

State, Local, or Tribal Governments - Survey Report Form Clinical Laboratory Improvement Amendments (CLIA) and supporting regulations in 42 CFR 493.1-493.2001

IC 202100 under ICR 201204-0938-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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 State, Local, or Tribal Governments - 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	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

State, Local, or Tribal Governments - 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: New

Obligation to Respond: Mandatory

CFR Citation:

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		Yes	No	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,290

Number of Respondents for Small Entity: 294

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	645	645
Annual IC Time Burden (Hours)	323	323
Annual IC Cost Burden (Dollars)	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.