Information Collection

Request for Employment Information

IC 8554 under ICR 202003-0938-014 · OMB 0938-0787.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0787 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-297 (CMS-L56 Request for Employment Information	Form and Instruction
CMS-R-297 (CMS-L56 Request for Employment Information CMS-L564_508.pdf	Form and Instruction
CMS-R-297 (CMS-L56 Solicitud De Informaciaon Sobre El Empleo CMS-L564S.pdf	Form and Instruction

IC Title:

Request for Employment Information

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 407.18 42 CFR 407.17 42 CFR 407.20

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-R-297 (CMS-L564)	Request for Employment Information	CMS-L564_508.pdf		Yes	No	Fillable Printable
Form and Instruction	CMS-R-297 (CMS-L564) SP	Solicitud De Informaciaon Sobre El Empleo	CMS-L564S.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,000

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	15,000	15,000
Annual IC Time Burden (Hours)	5,000	5,000
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.