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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
CMS-10781_Wireframe_Screenshots.pdf	Other-FOIA Intake Portal Screenshots
CMS-10781_Wireframe_Screenshots.pdf	Other-FOIA Intake Portal Screenshots

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:

table that charts list of 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 %

table that charts list of burden
	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

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.