Information Collection

403.906 and 404.908(a) - (g) - Applicable GPO Data Collection and Reporting

IC 207934 under ICR 201411-0938-010 · OMB 0938-1173.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10419 403.906 and 404.908(a) - (g) - Applicable GPO Data Collection and Reporting	Form and Instruction
CMS-10419 Template for Open Payment Data Elements Final rule Open Payments data elements PRA 10 29 14.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 403.906 42 CFR 403.908 42 CFR 404.908 42 CFR 403.904

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-10419	Template for Open Payment Data Elements	Final rule Open Payments data elements PRA 10 29 14.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 420

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	420	0	420
Annual IC Time Burden (Hours)	191,835	-62,965	254,800
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.