Information Collection

Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form

IC 7777 under ICR 201405-0938-002 · OMB 0938-0027.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0027 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-1880 Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form	Form and Instruction
CMS-1880 Request for Certification as a Supplier of Portable X-ra CMS 1880 Request For Certification.pdf	Form and Instruction
CMS-1882 Portable X-ray Survey Report CMS-1882_Rev_2014.pdf	Form and Instruction

IC Title:

Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 486.100

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-1880	Request for Certification as a Supplier of Portable X-ray Services	CMS 1880 Request For Certification.pdf		Yes	No	Fillable Printable
Form and Instruction	CMS-1882	Portable X-ray Survey Report	CMS-1882_Rev_2014.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 579

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	86	86
Annual IC Time Burden (Hours)	151	151
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.