Information Collection

Executive Summary for Research Identifiable Data (Private Sector)

IC 215655 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 (Private Sector)	Form and Instruction
CMS-10522 Executive Summary Supplement for Requestors of the NDI C 508_CMS_NDI.pdf	Form and Instruction
CMS-10522 EXECUTIVE SUMMARY FOR RESEARCH IDENTIFIABLE DATA CMS Vir 508_CMS_VDRC_508.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	Executive Summary Supplement for Requestors of the NDI Causes of Death Variables	508_CMS_NDI.pdf		Yes	Yes	Fillable Fileable Signable
Form and Instruction	CMS-10522	EXECUTIVE SUMMARY FOR RESEARCH IDENTIFIABLE DATA CMS Virtual Research Data Center (CMS VRDC) Request	508_CMS_VDRC_508.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: 295

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

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	295	295
Annual IC Time Burden (Hours)	590	590
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.