Information Collection

?§403.906 and 404.908(a)-(g) - Applicable GPO Data Collection and Reporting

IC 207934 under ICR 201305-0938-006 · OMB 0938-1173.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1173 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10419 ?§403.906 and 404.908(a)-(g) - Applicable GPO Data Collection and Reporting Form
CMS-10419 Research Template CMS-10419_Research Template.pdf Form
CMS-10419 Physician Ownership Template CMS-10419_Physician_Ownership_Template.pdf Form
CMS-10419 General Payments (Non-Research) Template CMS-10419_General_Payments_(Non-Research)_Template (5-15-13).pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	§§403.906 and 404.908(a)-(g) - Applicable GPO Data Collection and Reporting	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 403.906 42 CFR 403.908 42 CFR 404.908 42 CFR 403.904

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10419	Research Template	CMS-10419_Research Template.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10419	Physician Ownership Template	CMS-10419_Physician_Ownership_Template.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10419	General Payments (Non-Research) Template	CMS-10419_General_Payments_(Non-Research)_Template (5-15-13).pdf	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 420	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: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	420	420
Annual IC Time Burden (Hours)	254,800	254,800
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.