Request for Employment Information

Request for Employment Information (CMS-R-297/CMS-L564)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.