Information Collection

SHOP Screener

IC 206916 under ICR 201305-0938-007 · OMB 0938-1203.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1203 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10458 SHOP Screener SHOP Screener	Form and Instruction
CMS-10458 SHOP Screener CMS-10458_SHOP_Tracking_Screener.pdf	Form and Instruction

IC Title:

SHOP Screener

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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-10458				Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 750

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	100	100
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].