Information Collection

Supplemental Data Sheet (CMS-367d)

IC 222507 under ICR 202203-0938-002 · OMB 0938-0578.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0578 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-367d Supplemental Data Sheet (CMS-367d) Form
CMS-367d Contact Information Sheet CMS Form-367d_Manufacturer Contact Fillable Form_09.2021.Final.pdf Form
CMS-367d Contact Information Sheet CMS Form-367d_Manufacturer Contact Fillable Form_09.2021.Final.pdf Form
CMS Form-367d_Manufacturer Contact Form_Crosswalk_09.2021.pdf Crosswalk: CMS-367d IC Document
CMS Form-367d_Manufacturer Contact Form_Crosswalk_09.2021.pdf Crosswalk: CMS-367d IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Supplemental Data Sheet (CMS-367d)	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-367d	Contact Information Sheet	CMS Form-367d_Manufacturer Contact Fillable Form_09.2021.Final.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 780	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,560	62	1,498
Annual IC Time Burden (Hours)	1,560	62	1,498
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk: CMS-367d	CMS Form-367d_Manufacturer Contact Form_Crosswalk_09.2021.pdf	03/21/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.