Information Collection

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

IC 215654 under ICR 201503-0938-007 · OMB 0938-1276.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

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-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 %

table that charts list of burden
	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

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.