Executive Summary Form for Research Identifiable Data (CMS-10522)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10522 Executive Summary for Research Identifiable Data (Private Sector)	Form and Instruction	New	Available
Form CMS-10522 Executive Summary for Research Identifiable Data (State, Local, Tribal Gov't)	Form and Instruction	New	Available
508_CMS-10522_Supporting_Statement_Part_A.docx	Supporting Statement A	Uploaded 2015-03-12	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
215655	Executive Summary for Research Identifiable Data (Private Sector)	Form and Instruction	New
215654	Executive Summary for Research Identifiable Data (State, Local, Tribal Gov't)	Form and Instruction	New

ICR Details

OMB Control No: 0938-1276	ICR Reference No: 201503-0938-007
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Executive Summary Form for Research Identifiable Data (CMS-10522)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/08/2015
	Date Received in OIRA: 03/12/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2018	36 Months From Approved
Responses	325	0	0
Time Burden (Hours)	650	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The CMS is responsible for administering the Medicare, Medicaid and State Children's Health Insurance Programs. We collect data to support the Agency's mission and operations. These data include information about Medicare beneficiaries, Medicare claims, Medicare providers, and Medicaid eligibility and claims. We disclose the identifiable data consistent with the routine uses identified in the Privacy Act Systems of Records notices that are published in the Federal Register and the limitations on uses and disclosures that are set out in the HIPAA Privacy Rule. All requests for identifiable data are received and reviewed by the Division of Privacy Operations & Compliance (DPOC) in the Office of E-Health Standards and Services. The DPOC staff and the CMS Privacy Officer review the requests to determine if there is legal authorization for disclosure of the data. If legal authorization exists, the request is reviewed to ensure that the minimal data necessary is requested and approved for the project. Requests for identifiable data for research purposes must be submitted to and approved by the CMS Privacy Board. To assist the CMS Privacy Board with its review of research data requests, OIPDA has developed the Executive Summary (ES) forms. The ES collects all the information that the CMS Privacy Board needs to review and make a determination on whether the request meets the requirements for release of identifiable data for research purposes. We currently have three versions of the ES Form and an ES Supplement for Requestors of the National Death Index (NDI) Causes of Death Variables. Each meets the need for a different type of requestor.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 40105	07/11/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 10688	02/27/2015
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Executive Summary for Research Identifiable Data (Private Sector)	CMS-10522, CMS-10522	Executive Summary Supplement for Requestors of the NDI Causes of Death Variables ,   EXECUTIVE SUMMARY FOR RESEARCH IDENTIFIABLE DATA CMS Virtual Research Data Center (CMS VRDC) Request
Executive Summary for Research Identifiable Data (State, Local, Tribal Gov't)	CMS-10522, CMS-10522	STATE EXECUTIVE SUMMARY FOR RESEARCH IDENTIFIABLE DATA ,   Executive Summary Supplement for Requestors of the NDI Causes of Death Variables

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	325	0	0	325	0	0
Annual Time Burden (Hours)	650	0	0	650	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection request.

---

Annual Cost to Federal Government: $162

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/12/2015

---