Information Collection

Federal Government - Survey Report Form Clinical Laboratory Improvement Amendments (CLIA) and supporting regulations in 42 CFR 493.1-493.2001

IC 202101 under ICR 202111-0938-003 · OMB 0938-0544.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-1557 Federal Government - Survey Report Form Clinical Laboratory Improvement Amendments (CLIA) and supporting regulations in 42 CFR 493.1-493.2001	Form and Instruction
CMS-1557 Survey Report Form (CLIA) cms1557.pdf	Form and Instruction
CMS-1557 Survey Report Form (CLIA) cms1557.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Mandatory

CFR Citation:

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-1557	Survey Report Form (CLIA)	cms1557.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 77

Number of Respondents for Small Entity: 38

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-39	39
Annual IC Time Burden (Hours)	-19	19
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.