Information Collection

Request for Employment Information

IC 8554 under ICR 202412-0938-006 · OMB 0938-0787.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-297 (CMS-L56 Request for Employment Information	Form and Instruction
Form CMS-R-297 (CMS-L56 Request for Employment Information Request for Employment Information	Form and Instruction
Form CMS-R-297 (CMS-L56 Request for Employment Information-Spanish Request for Employment Information	Form and Instruction
Form CMS-R-297 (CMS-L56 Request for Employment Information- Chinese Request for Employment Information	Form and Instruction
Form CMS-R-297 (CMS-L56 Request for Employment Information- Korean Request for Employment Information	Form and Instruction
Form CMS-R-297 (CMS-L56 Request for Employment Information- Vietnamese Request for Employment Information	Form and Instruction
CMS-R-297 (CMS-L56 Request for Employment Information CMS-L564-508C (005).docx	Form and Instruction
CMS-R-297 (CMS-L56 Request for Employment Information CMS-L564-508C (005).docx	Form and Instruction
CMS-R-297 (CMS-L56 Request for Employment Information-Spanish Spanish CMS-L564-508C (005)_508_form_rev.docx	Form and Instruction
CMS-R-297 (CMS-L56 Request for Employment Information-Spanish Spanish CMS-L564-508C (005)_508_form_rev.docx	Form and Instruction
CMS-R-297 (CMS-L56 Request for Employment Information- Chinese Chinese CMS-L564-508C (005)_508_form.docx	Form and Instruction
CMS-R-297 (CMS-L56 Request for Employment Information- Chinese Chinese CMS-L564-508C (005)_508_form.docx	Form and Instruction
CMS-R-297 (CMS-L56 Request for Employment Information- Korean Korean CMS-L564-508C (005)_508_form.docx	Form and Instruction
CMS-R-297 (CMS-L56 Request for Employment Information- Korean Korean CMS-L564-508C (005)_508_form.docx	Form and Instruction
CMS-R-297 (CMS-L56 Request for Employment Information- Vietnamese Vietnamese CMS-L564-508C (005)_508_form.docx	Form and Instruction
CMS-R-297 (CMS-L56 Request for Employment Information- Vietnamese Vietnamese CMS-L564-508C (005)_508_form.docx	Form and Instruction
CMS-L564 Redline.docx Request for Employment Information - Redline	IC Document
CMS-L564 Redline.docx Request for Employment Information - Redline	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Request for Employment Information

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 407.17 42 CFR 407.18 42 CFR 407.20

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-297 (CMS-L564)	Yes	No	Fillable Printable
Form and Instruction	CMS-R-297 (CMS-L564)	Yes	No	Fillable Printable
Form and Instruction	CMS-R-297 (CMS-L564)	Yes	No	Fillable Printable
Form and Instruction	CMS-R-297 (CMS-L564)	Yes	No	Fillable Fileable
Form and Instruction	CMS-R-297 (CMS-L564)	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 594,998

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,189,996	513,470	676,526
Annual IC Time Burden (Hours)	297,499	128,367	169,132
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request for Employment Information - Redline		12/09/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].