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pdfDepartment 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
20 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the
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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| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |