Information Collection

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

IC 8201 under ICR 201404-0938-006 · OMB 0938-0599.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0599 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-102 CLIA Budget Workload Reports and Supporting Regulations Contained in 42 CFR 493.1-.2001 (CMS-102, CMS-105)	Form and Instruction
CMS-102 CLIA Budget/Expenditure Report CMS-102 form.pdf	Form and Instruction
CMS-105 Planned Workload Report 10511.pdf	Form and Instruction

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 493.1-.2001

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-102	CLIA Budget/Expenditure Report	CMS-102 form.pdf		Yes	Yes	Fillable Printable
Form and Instruction	CMS-105	Planned Workload Report	10511.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	4,500	4,500
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.