CMS-105 Planned Workload Report

CLIA Budget Workload Reports and Supporting Regulations (CMS-102, CMS-105)

10511

CLIA Budget Workload Reports and Supporting Regulations Contained in 42 CFR 493.1-.2001 (CMS-102, CMS-105)

OMB: 0938-0599

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Department of Health and Human Services
Centers for Medicare & Medicaid Services

Form Approved
OMB NO 0938-0599

Planned Workload Report
Clinical Laboratory Improvement Amendments Program
According to Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
The valid OMB control number for this information collection is 0938-0599. The time required to complete this information collection is estimated to average 8 to
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information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Region/State Code:

FY Quarter: 2/2004

4 / Alabama

From: 1/1/2004 To: 3/31/2004

Agency Name:
Alabama Department of Public Health

Type of Laboratory

Number
Of Sites
(A)

Initial
Visits
(B)

Resurvey

Follow-Up

Visits
(C)

Visits
(D)

Compliant
Visits
(E)

Total
Visits
(F)

1

Waived/PPMP

0

0

0

0

0

0

2

Accredited

0

0

0

0

0

0

3

Low Volume Schedule

0

0

0

0

0

0

4

Schedule A

0

0

0

0

0

0

5

Schedule B

0

0

0

0

0

0

6

Schedule C

0

0

0

0

0

0

7

Schedule D

0

0

0

0

0

0

8

Schedule E

0

0

0

0

0

0

9

Schedule F

0

0

0

0

0

0

10

Schedule G

0

0

0

0

0

0

11

Schedule H

0

0

0

0

0

0

12

Schedule I

0

0

0

0

0

0

13

Schedule J

0

0

0

0

0

0

14

Totals

0

0

0

0

0

0

Date:

Form CMS - 105

Signature:

Title:

Date Revised: 04/28/2004

Wednesday, April 28, 2004 - 03:44 PM


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