Information Collection

21st Century Cures Act Section 12002 IMD Study Survey

IC 234817 under ICR 201902-0938-002 · OMB 0938-1359.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10684 21st Century Cures Act Section 12002 IMD Study Survey	Form
Survey Glossary (version 2).docx	Instruction
Summary of Relevant Regulations and Legislation (version 2).docx	Other-Web Posting: Summary of Regula
CMS-10684 21st Century Cures Act Section 12002 IMD Study Survey 21st Century Cures Act Section 12002 Study SURVEY (version 2).docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10684	21st Century Cures Act Section 12002 IMD Study Survey	21st Century Cures Act Section 12002 Study SURVEY (version 2).docx	Yes	Yes	Fillable Fileable
Instruction			Survey Glossary (version 2).docx	Yes	No	Printable Only
Other-Web Posting: Summary of Regulations and Legislation			Summary of Relevant Regulations and Legislation (version 2).docx	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 43

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	43	43
Annual IC Time Burden (Hours)	86	86
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.