Information Collection

CLIA Budget Workload Reports and Supporting Regulations Contained in 42 CFR 493.1-.2001 (CMS-102, CMS-105)

IC 8201 under ICR 202402-0938-011 · OMB 0938-0599.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-102 CLIA Budget Workload Reports and Supporting Regulations Contained in 42 CFR 493.1-.2001 (CMS-102, CMS-105)	Form
som107c06 - CMS-102 CMS-105 instructions.pdf	Instruction
som107c06 - CMS-102 CMS-105 instructions.pdf	Instruction
CMS-102 CLINICAL LABORATORY IMPROVEMENT AMENDMENTS PROGRAM BUDGE CMS-102- Instrument.xlsx	Form
CMS-102 CLINICAL LABORATORY IMPROVEMENT AMENDMENTS PROGRAM BUDGE CMS-102- Instrument.xlsx	Form
CMS-105 CLINICAL LABORATORY IMPROVEMENT AMENDMENTS PROGRAM PLANN CMS-105- Instrument.xlsx	Form
CMS-105 CLINICAL LABORATORY IMPROVEMENT AMENDMENTS PROGRAM PLANN CMS-105- Instrument.xlsx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 493.1-.2001

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-102	CLINICAL LABORATORY IMPROVEMENT AMENDMENTS PROGRAM BUDGET/EXPENDITURE REPORT	CMS-102- Instrument.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-105	CLINICAL LABORATORY IMPROVEMENT AMENDMENTS PROGRAM PLANNED WORKLOAD REPORT	CMS-105- Instrument.xlsx	Yes	Yes	Fillable Fileable
Instruction			som107c06 - CMS-102 CMS-105 instructions.pdf	Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	1,700	1,700
Annual IC Cost Burden (Dollars)	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.