Information Collection

Request Process

IC 249860 under ICR 202110-0938-011 · OMB 0938-1419.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1419 can be found here:

Documents and Forms

Document Name Document Type
CMS-10781_Wireframe_Screenshots.pdf Other-FOIA Intake Portal Screenshots
CMS-10781_Wireframe_Screenshots.pdf Other-FOIA Intake Portal Screenshots

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request Process	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 5.22 45 CFR 5.24 45 CFR 164.508 42 CFR 401.136

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-FOIA Intake Portal Screenshots			CMS-10781_Wireframe_Screenshots.pdf		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: HHS SORN 09-90-0058 Tracking Records and Case Files for FOIA and Privacy Act Requests and Appeals	FR Citation: 81 FR 17463

Number of Respondents: 19,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	19,000	19,000
Annual IC Time Burden (Hours)	6,333	6,333
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.