Information Collection

Supplemental Data Sheet (CMS-367d)

IC 222507 under ICR 201912-0938-003 · OMB 0938-0578.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0578 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-367d Supplemental Data Sheet (CMS-367d) Form
CMS-367d Contact Information Sheet 367d_August 2019_Final.docx.pdf Form
367d_August 2019_Track Changes.docx CMS-367d - Track Changes IC Document
Form Record Specification Crosswalk_367b_August 2019.xlsx CMS-367d - Crosswalk IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Supplemental Data Sheet (CMS-367d)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-367d	Contact Information Sheet	367d_August 2019_Final.docx.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 743	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,486	266	1,220
Annual IC Time Burden (Hours)	1,486	266	1,220
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-367d - Track Changes	367d_August 2019_Track Changes.docx	12/12/2019
CMS-367d - Crosswalk	Form Record Specification Crosswalk_367b_August 2019.xlsx	12/12/2019

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