Information Collection

Monthly Sampling Lists

IC 46144 under ICR 202405-0938-026 · OMB 0938-1012.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1012 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10184 Monthly Sampling Lists Form
CMS-10184 Monthly Sample Selection List -CMS-10184.Monthly Sample Selection List.doc Form
CMS-10184 Monthly Sample Selection List -CMS-10184.Monthly Sample Selection List.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Monthly Sampling Lists	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10184	Monthly Sample Selection List	-CMS-10184.Monthly Sample Selection List.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 34	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	-408	408
Annual IC Time Burden (Hours)	-40,800	40,800
Annual IC Cost Burden (Dollars)	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.