Information Collection

Statement of Deficiencies and Plan of Correction

IC 8038 under ICR 202107-0938-004 · OMB 0938-0391.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0391 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-2567 Statement of Deficiencies and Plan of Correction Form and Instruction
CMS-2567 Statement of Deficiencies and Plan of Correction CMS2567. 06.10.21.pdf Form and Instruction
CMS-2567 Statement of Deficiencies and Plan of Correction CMS2567. 06.10.21.pdf Form and Instruction
Change Crosswalk for CMS-2567. 06.10.21 (1).docx Crosswalk IC Document
Change Crosswalk for CMS-2567. 06.10.21 (1).docx Crosswalk IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Statement of Deficiencies and Plan of Correction	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 and Instruction	CMS-2567	Statement of Deficiencies and Plan of Correction	CMS2567. 06.10.21.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 65,948	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	65,948	1,448	64,500
Annual IC Time Burden (Hours)	1,210,376	1,070,626	139,750
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Change Crosswalk for CMS-2567. 06.10.21 (1).docx	07/13/2021

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