CLIA Budget Workload Reports and Supporting Regulations Contained in 42 CFR 493.1-.2001 (CMS-102, CMS-105)

CLIA Budget Workload Reports and Supporting Regulations (CMS-102, CMS-105)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0599 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-102 CLIA Budget Workload Reports and Supporting Regulations Contained in 42 CFR 493.1-.2001 (CMS-102, CMS-105) Form and Instruction
CMS-102 CLIA Budget/Expenditure Report CMS-102_form 11-8-17.pdf Form and Instruction
CMS-105 Planned Workload Report CMS-105_form 11-8-17.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	CLIA Budget Workload Reports and Supporting Regulations Contained in 42 CFR 493.1-.2001 (CMS-102, CMS-105)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 493.1-.2001

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-102	CLIA Budget/Expenditure Report	CMS-102_form 11-8-17.pdf		Yes	Yes	Fillable Printable
Form and Instruction	CMS-105	Planned Workload Report	CMS-105_form 11-8-17.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	50	0	50
Annual IC Time Burden (Hours)	1,700	-2,800	4,500
Annual IC Cost Burden (Dollars)	0	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.