Information Collection

State and Local governments

IC 209056 under ICR 201705-0938-012 · OMB 0938-1235.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10471 Revised PMD Stakeholders Screening and Scheduling Guide State and Local governments	Form and Instruction
CMS-10471.Background Research Discussion Guide.docx	Instruction
CMS-10471 Revised PMD Stakeholders Screening and Scheduling Guide Revised PMD Stakeholders Screening and Scheduling Guide.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Instruction			CMS-10471.Background Research Discussion Guide.docx		Yes	No	Fillable Fileable
Form and Instruction	CMS-10471	Revised PMD Stakeholders Screening and Scheduling Guide	Revised PMD Stakeholders Screening and Scheduling Guide.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 38

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	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	38	10	28
Annual IC Time Burden (Hours)	48	13	35
Annual IC Cost Burden (Dollars)	0	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.