Cms-105 Clinical Laboratory Improvement Amendments Program Plann

Accomplished/Planned Workload Report
Clinical Laboratory Improvement Amendments Program
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. This is a voluntary information collection. The CMS-105 captures the annual projected CLIA workload that the State survey agency will accomplish. It is also used by the CMS Locations to approve the annual projected CLIA workload. The valid OMB control number for this information collection is 0938-0599. The time required to complete this voluntary , non-confidential information collection is estimated to average 4 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained.
Location/State Code:			FY Quarter:
			From:
Agency Name
Type of Laboratory	Number Of Sites	Initial Visits	Resurvey Visits	Follow-Up Visits	Complaint Visits	Total Visits
	(A)	(B)	(C)	(D)	(E)	(F)
1) Waived/PPMP
2) Accredited
3) Low Volume Schedule
4) Schedule A
5) Schedule B
6) Schedule C
7) Schedule D
8) Schedule E
9) Schedule F
10) Schedule G
11) Schedule H
12) Schedule I
13) Schedule J
14) Totals
Date:	Signature:			Title: