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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.