(CMS-10648) LAN Forum –Event Evaluations

Generic Clearance for the Heath Care Payment Learning and Action Network (CMS-10575)

⚠️ Notice: This information collection may be referencing outdated material.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

Information Collection (IC) Details

IC Title:	(CMS-10648) LAN Forum –Event Evaluations	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.