Information Collection

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

IC 8149 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 Survey Report Form Clinical Laboratory Improvement Amendments (CLIA) and supporting regulations in 42 CFR 493.1-493.2001	Form and Instruction
Form CMS-1557 Survey Report Form (CLIA) Survey Report Form Clinical Laboratory Improvement Amendments (CLIA) and supporting regulations in 42 CFR 493.1-493.2001	Form and Instruction
1557 entry instructions ASPEN 11.9.1 Procedures Guide (004).pdf	Instruction
1557 entry instructions ASPEN 11.9.1 Procedures Guide (004).pdf	Instruction
CMS-1557 Survey Report Form (CLIA) CMS1557-508-FINAL.pdf	Form and Instruction
CMS-1557 Survey Report Form (CLIA) CMS1557-508-FINAL.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 493.1-493.2001

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				Yes	No	Fillable Fileable
Instruction					Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,975

Number of Respondents for Small Entity: 7,029

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	7,988	-917	8,905
Annual IC Time Burden (Hours)	3,994	-459	4,453
Annual IC Cost Burden (Dollars)	0	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.

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