Information Collection

LAN Documents (CMS-10612, CMS-10613 and CMS-10614)

IC 220737 under ICR 201509-0938-006 · OMB 0938-1297.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1297 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10612 LAN Documents (CMS-10612, CMS-10613 and CMS-10614) Form and Instruction
CMS-10612 Webinar Registration - LAN Listening CMS-10612 GenIC7 Instrument - Webinar Registration Form.pptx Form and Instruction
CMS-10613 LAN Summit Session Evaluation Form CMS-10613 GenIC8 Instrument - LAN Summit Session Eval Form.pdf Form and Instruction
CMS-10614 LAN Summit Evaluation Form CMS-10614 GenIC9 Instrument - LAN Summit Eval Form.pdf Form and Instruction
CMS-10612 GenIC7 Webinar Registration - LAN Listening v2.docx CMS-10612 Supporting Statement IC Document
CMS-10613 GenIC8 LAN Summit Session Evaluation Form.docx CMS-10613 Supporting Statement IC Document
CMS-10614 GenIC9 LAN Summit Evaluation Form.docx CMS-10614 Supporting Statement IC Document
0938-1297 Burden Table for GenICs 7 8 and 9.docx 0938-1297 Burden Table for GenICs 7 8 and 9 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	LAN Documents (CMS-10612, CMS-10613 and CMS-10614)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10612	Webinar Registration - LAN Listening	CMS-10612 GenIC7 Instrument - Webinar Registration Form.pptx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10613	LAN Summit Session Evaluation Form	CMS-10613 GenIC8 Instrument - LAN Summit Session Eval Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10614	LAN Summit Evaluation Form	CMS-10614 GenIC9 Instrument - LAN Summit Eval Form.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,400	Number of Respondents for Small Entity: 880

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,400	4,400
Annual IC Time Burden (Hours)	231	231
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10612 Supporting Statement	CMS-10612 GenIC7 Webinar Registration - LAN Listening v2.docx	03/23/2016
CMS-10613 Supporting Statement	CMS-10613 GenIC8 LAN Summit Session Evaluation Form.docx	03/23/2016
CMS-10614 Supporting Statement	CMS-10614 GenIC9 LAN Summit Evaluation Form.docx	03/23/2016
0938-1297 Burden Table for GenICs 7 8 and 9	0938-1297 Burden Table for GenICs 7 8 and 9.docx	03/23/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.