State, Local, or Tribal Governments - Survey Report Form Clinical Laboratory Improvement Amendments (CLIA) and supporting regulations in 42 CFR 493.1-493.2001

Survey Report Form Clinical Laboratory Improvement Amendments (CLIA) and supporting regulations (CMS-1557)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0544 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-1557 State, Local, or Tribal Governments - Survey Report Form Clinical Laboratory Improvement Amendments (CLIA) and supporting regulations in 42 CFR 493.1-493.2001 Form and Instruction
CMS-1557 Survey Report Form (CLIA) cms1557.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	State, Local, or Tribal Governments - Survey Report Form Clinical Laboratory Improvement Amendments (CLIA) and supporting regulations in 42 CFR 493.1-493.2001	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-1557	Survey Report Form (CLIA)	cms1557.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,319	Number of Respondents for Small Entity: 294

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	660	15	645
Annual IC Time Burden (Hours)	330	7	323
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.