Information Collection

CMS-10437.GenIC#21 - Testing Form 500

IC 244633 under ICR 201708-0938-025 · OMB 0938-1247.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1247 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10437.GenIC#21 CMS-10437.GenIC#21 - Testing Form 500	Form and Instruction
CMS-10437.GenIC#21 CMS-10437.GenIC#21 - Guide for Testing Form500 (final 11 CMS-10437.GenIC#21 - Guide for Testing Form500 (final 11-24-20).docx	Form and Instruction
CMS-10437.GenIC#21-Form500Testing_Supporting Statement (final 11-24-20).docx CMS-10437.GenIC#21-Form500Testing_Supporting Statement (final 11-24-20)	IC Document
CMS-10437.GenIC#21 - Justification for Providing Incentives for Participation in Marketing Research.docx CMS-10437.GenIC#21 - Justification for Providing Incentives for Participation in Marketing Research	IC Document
CMS-10437.GenIC#21 - Form500StudyInitiationRequestForm.docx CMS-10437.GenIC#21 - Form500StudyInitiationRequestForm	IC Document

IC Title:

CMS-10437.GenIC#21 - Testing Form 500

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-10437.GenIC#21 - Guide for Testing Form500 (fi	CMS-10437.GenIC#21 - Guide for Testing Form500 (final 11-24-20)	CMS-10437.GenIC#21 - Guide for Testing Form500 (final 11-24-20).docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 27

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	27	27
Annual IC Time Burden (Hours)	27	27
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10437.GenIC#21-Form500Testing_Supporting Statement (final 11-24-20)	CMS-10437.GenIC#21-Form500Testing_Supporting Statement (final 11-24-20).docx	11/25/2020
CMS-10437.GenIC#21 - Justification for Providing Incentives for Participation in Marketing Research	CMS-10437.GenIC#21 - Justification for Providing Incentives for Participation in Marketing Research.docx	11/25/2020
CMS-10437.GenIC#21 - Form500StudyInitiationRequestForm	CMS-10437.GenIC#21 - Form500StudyInitiationRequestForm.docx	11/25/2020

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