Information Collection

Monthly Sampling Lists

IC 46144 under ICR 201609-0938-031 · OMB 0938-1012.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1012 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10184 Monthly Sampling Lists	Form
CMS-10184 Monthly Sample Selection List -CMS-10184.Monthly Sample Selection List.doc	Form

IC Title:

Monthly Sampling Lists

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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	CMS-10184	Monthly Sample Selection List	-CMS-10184.Monthly Sample Selection List.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 34

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	408	408
Annual IC Time Burden (Hours)	40,800	40,800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.