Information Collection

Environmental Health Hazards Checklist

IC 272603 under ICR 202411-0938-009 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10902 Environmental Health Hazards Checklist	Form and Instruction
CMS-10902 Environmental Health Hazards Checklist (English) CMS-XXXX-Environmental Health Hazards Checklist.docx	Form and Instruction
CMS-10902 Environmental Health Hazards Checklist (English) CMS-XXXX-Environmental Health Hazards Checklist.docx	Form and Instruction
CMS-10902 Environmental Health Hazards Checklist (Spanish) CMS-XXXX-S-Environmental Health Hazards Checklist.docx	Form and Instruction
CMS-10902 Environmental Health Hazards Checklist (Spanish) CMS-XXXX-S-Environmental Health Hazards Checklist.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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-10902	Environmental Health Hazards Checklist (English)	CMS-XXXX-Environmental Health Hazards Checklist.docx		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10902	Environmental Health Hazards Checklist (Spanish)	CMS-XXXX-S-Environmental Health Hazards Checklist.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: SSAâs Master Beneficiary Record (MBR)

FR Citation: 83 FR 54969

Number of Respondents: 61

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	61	61
Annual IC Time Burden (Hours)	10	10
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.