Information Collection

Level II Monitoring Data Entry

IC 213218 under ICR 201412-0938-004 · OMB 0938-1264.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1264 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10525 Level II Monitoring Data Entry	Form and Instruction
CMS-10525 Level Two Conference Call Worksheet LEVEL TWO CONFERENCE CALL WORKSHEET 1 TEMPLATE PRA May 1 2014.doc	Form and Instruction
CMS-10525 Level Two Incident Intake Summary LEVEL TWO INCIDENT INTAKE SUMMARY TEMPLATE PRA May 1 2014(2).doc	Form and Instruction

IC Title:

Level II Monitoring Data Entry

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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-10525	Level Two Conference Call Worksheet	LEVEL TWO CONFERENCE CALL WORKSHEET 1 TEMPLATE PRA May 1 2014.doc		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10525	Level Two Incident Intake Summary	LEVEL TWO INCIDENT INTAKE SUMMARY TEMPLATE PRA May 1 2014(2).doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to New Statute	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	40,000	-40,000
Annual IC Time Burden (Hours)	40,000	-40,000
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.