Information Collection

2017 801 MSI Questionnaire_CMS Final _Approved 3-3-17

IC 226004 under ICR 201412-1090-003 · OMB 1090-0007.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1090-0007 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 801 2017 801 MSI Questionnaire_CMS Final _Approved 3-3-17	Form and Instruction
801 2017 801 MSI Questionnaire_CMS Final _Approved 3-3-17 2017 801 MSI Questionnaire_CMS Final _Approved 3-3-17.docx	Form and Instruction

IC Title:

2017 801 MSI Questionnaire_CMS Final _Approved 3-3-17

Agency IC Tracking Number:

801

IC Status: New

Obligation to Respond: Voluntary

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	801	2017 801 MSI Questionnaire_CMS Final _Approved 3-3-17	2017 801 MSI Questionnaire_CMS Final _Approved 3-3-17.docx		Yes	Yes	Fillable Printable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 250

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	50	50
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.