Information Collection

Supplemental Data Sheet (CMS-367d)

IC 222507 under ICR 201607-0938-008 · OMB 0938-0578.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0578 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-367d Supplemental Data Sheet (CMS-367d) Form
CMS-367d Supplemental Data Sheet Form367(d).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Supplemental Data Sheet (CMS-367d)	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-367d	Supplemental Data Sheet	Form367(d).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 610	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,220	1,220
Annual IC Time Burden (Hours)	1,220	1,220
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.