Information Collection

Request for Employment Information (CMS-R-297)

IC 8554 under ICR 201308-0938-009 · OMB 0938-0787.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0787 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-L564 (CMS-R-29 Request for Employment Information (CMS-R-297)	Form
CMS-L564 (CMS-R-29 Request for Employment Information Form CMS-L564.pdf	Form

IC Title:

Request for Employment Information (CMS-R-297)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 407.17 42 CFR 407.18 42 CFR 407.20

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	CMS-L564 (CMS-R-297)	Request for Employment Information	Form CMS-L564.pdf		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,000

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: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	15,000	10,000	5,000
Annual IC Time Burden (Hours)	3,750	2,500	1,250
Annual IC Cost Burden (Dollars)	0	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.