Statement of Deficiencies and Plan of Correction

Statement of Deficiencies and Plan of Correction (CMS-2567)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0391 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-2567 Statement of Deficiencies and Plan of Correction Form and Instruction
CMS-2567 Statement of Deficiencies and Plan of Correction CMS2567-508.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Statement of Deficiencies and Plan of Correction	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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-2567	Statement of Deficiencies and Plan of Correction	CMS2567-508.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 62,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	62,000	2,000	60,000
Annual IC Time Burden (Hours)	134,333	14,333	120,000
Annual IC Cost Burden (Dollars)	0	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.