Information Collection

Statement of Deficiencies and Plan of Correction

IC 8038 under ICR 202201-0938-003 · OMB 0938-0391.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-2567 Statement of Deficiencies and Plan of Correction	Form and Instruction
Form CMS-2567 Statement of Deficiencies and Plan of Correction Statement of Deficiencies and Plan of Correction	Form and Instruction
CMS-2567 Statement of Deficiencies and Plan of Correction CMS2567. 09.27.21.pdf	Form and Instruction
CMS-2567 Statement of Deficiencies and Plan of Correction CMS2567. 09.27.21.pdf	Form and Instruction

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:

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-2567				Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 65,948

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	65,948	0	65,948
Annual IC Time Burden (Hours)	1,187,064	-23,312	1,210,376
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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