Information Collection

Organ Procurement Organization/Histcompatibility Laboratory Statement of Reimbursable Costs, Manual Instructions (CMS-216-94)

IC 43650 under ICR 202409-0938-021 · OMB 0938-0102.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 216-94 Organ Procurement Organization/Histcompatibility Laboratory Statement of Reimbursable Costs, Manual Instructions (CMS-216-94)	Form
Form 216-94 Organ Procurement Organization/Histocompatibility Laboratory Cost Report Organ Procurement Organization/Histcompatibility Laboratory Statement of Reimbursable Costs, Manual Instructions (CMS-216-94)	Form
Organ Procurement OrganizationHistocompatibility Laboratory Cost Report Instruction.docx	Instruction
Organ Procurement OrganizationHistocompatibility Laboratory Cost Report Instruction.docx	Instruction
216-94 Organ Procurement Organization/Histocompatibility Labora 216-94 Form.xlsx	Form
216-94 Organ Procurement Organization/Histocompatibility Labora 216-94 Form.xlsx	Form

IC Title:

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 413.20 42 CFR 413.24

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	216-94				Yes	Yes	Fillable Fileable
Instruction					Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 95

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	95	95
Annual IC Time Burden (Hours)	4,275	4,275
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.

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