Information Collection

(CMS-10648) LAN Forum –Event Evaluations

IC 226339 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⚠️ Notice: This information collection may be referencing outdated material.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-10648 (CMS-10648) LAN Forum –Event Evaluations	Form and Instruction
CMS-10648 LAN Forum Evaluation Form CMS-10648 GenIC15 LAN Forum Evaluation Form Questions.docx	Form and Instruction
CMS-10648 GenIC15 LAN Forum Evaluation Form Request.docx CMS-10648 LAN GenIC15 Supporting Statement	IC Document

IC Title:

(CMS-10648) LAN Forum âEvent Evaluations

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10648	LAN Forum Evaluation Form	CMS-10648 GenIC15 LAN Forum Evaluation Form Questions.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 200

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	500	500
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10648 LAN GenIC15 Supporting Statement	CMS-10648 GenIC15 LAN Forum Evaluation Form Request.docx	04/10/2017

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