Information Collection

Form completetion

IC 236195 under ICR 202208-0938-022 · OMB 0938-1210.

Documents and Forms

Document Name Document Type
Form CMS-10455 Form completetion Form and Instruction
CMS-10455 Screenshots of Electronic Submission CMS 10455 Screenshots of the Electronic Submission Process.pdf Form and Instruction
CMS-10455 Screenshots of Electronic Submission CMS 10455 Screenshots of the Electronic Submission Process.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Form completetion	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 482 Section 13

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10455	Screenshots of Electronic Submission	CMS 10455 Screenshots of the Electronic Submission Process.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Automated Survey Prcoessing Environment (ASPEN)	FR Citation: 71 FR 29644

Number of Respondents: 3,137	Number of Respondents for Small Entity: 3,137

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	3,137	1,156	1,981
Annual IC Time Burden (Hours)	784	293	491
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.