Information Collection

Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form

IC 7777 under ICR 202108-0938-004 · OMB 0938-0027.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-1880 Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form	Form and Instruction
CMS-1880 Request for Certification as Supplier of Portable Xray E Form CMS-1880.pdf	Form and Instruction
Change Crosswalk for CMS-1880. 03.01.21.docx Crosswalk	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 486.100

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-1880	Request for Certification as Supplier of Portable Xray Equipment	Form CMS-1880.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 505

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	104	18	86
Annual IC Time Burden (Hours)	26	4	22
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	Change Crosswalk for CMS-1880. 03.01.21.docx	08/13/2021

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