OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Request for Employment Information

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

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Request for Employment Information
 
No Modified
 
Voluntary
 
42 CFR 407.17 42 CFR 407.18 42 CFR 407.20

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-R-297 (CMS-L564) Request for Employment Information CMS-L564-508C (005).docx Yes No Fillable Printable
Form and Instruction CMS-R-297 (CMS-L564) Request for Employment Information-Spanish Spanish CMS-L564-508C (005)_508_form_rev.docx Yes No Fillable Printable
Form and Instruction CMS-R-297 (CMS-L564) Request for Employment Information- Chinese Chinese CMS-L564-508C (005)_508_form.docx Yes No Fillable Printable
Form and Instruction CMS-R-297 (CMS-L564) Request for Employment Information- Korean Korean CMS-L564-508C (005)_508_form.docx Yes No Fillable Fileable
Form and Instruction CMS-R-297 (CMS-L564) Request for Employment Information- Vietnamese Vietnamese CMS-L564-508C (005)_508_form.docx Yes No Fillable Printable

Health Health Care Services

 

594,998 0
   
Individuals or Households
 
   0 %

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

Title Document Date Uploaded
Request for Employment Information - Redline CMS-L564 Redline.docx 12/09/2024
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.