Information Collection

Data Collection for Medicare Beneficiaries Receiving Implantable Cardioverter-defibrillators for Primary Prevention of Sudden Cardiac Death

IC 8827 under ICR 201308-0938-018 · OMB 0938-0967.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0967 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ICDDataDictionaryv1 0.pdf	Instruction
CMS-10151 CMS-10151 Instrument ICD_v2_DataCollectionForm_GenLeads_2 1_508 compliant.pdf	Form

IC Title:

Data Collection for Medicare Beneficiaries Receiving Implantable Cardioverter-defibrillators for Primary Prevention of Sudden Cardiac Death

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			ICDDataDictionaryv1 0.pdf		Yes	No	Fillable Fileable
Form	CMS-10151	CMS-10151 Instrument	ICD_v2_DataCollectionForm_GenLeads_2 1_508 compliant.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Data Collection Secondary to Coverage Decision System

FR Citation: 70 FR 53667

Number of Respondents: 1,702

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	20,424	-29,576	50,000
Annual IC Time Burden (Hours)	139,656	127,156	12,500
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.