Laboratory Personnel Report (CMS-209)

Laboratory Personnel Report (CLIA) and Supporting Regulations (CMS-209)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0151 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-209 Laboratory Personnel Report (CMS-209) Form and Instruction
CMS-209 Laboratory Personnel Report (CLIA) CMS-209 formm .23Jan 2018.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Laboratory Personnel Report (CMS-209)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 493.1-493.2001

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-209	Laboratory Personnel Report (CLIA)	CMS-209 formm .23Jan 2018.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 77	Number of Respondents for Small Entity: 39

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	39	-3	42
Annual IC Time Burden (Hours)	19	-2	21
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.