Executive Summary for Research Identifiable Data (State, Local, Tribal Gov't)

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

Documents and Forms

Document Name Document Type
Form CMS-10522 Executive Summary for Research Identifiable Data (State, Local, Tribal Gov't) Form and Instruction
CMS-10522 STATE EXECUTIVE SUMMARY FOR RESEARCH IDENTIFIABLE DATA 508_CMS-10522_StateExecSumm.pdf Form and Instruction
CMS-10522 Executive Summary Supplement for Requestors of the NDI C 508_CMS_NDI.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Executive Summary for Research Identifiable Data (State, Local, Tribal Gov't)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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-10522	STATE EXECUTIVE SUMMARY FOR RESEARCH IDENTIFIABLE DATA	508_CMS-10522_StateExecSumm.pdf		Yes	Yes	Fillable Fileable Signable
Form and Instruction	CMS-10522	Executive Summary Supplement for Requestors of the NDI Causes of Death Variables	508_CMS_NDI.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	Number of Respondents for Small Entity: 20

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	60	60
Annual IC Cost Burden (Dollars)	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.