Information Collection

Form completetion

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

Documents and Forms

Documents and forms in this information collection
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

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:

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-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 %

table that charts list of burden
	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

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.