Information Collection

Integrated HRAs (Work to integrate HRAs)

IC 273855 under ICR 202501-0938-013 · OMB 0938-1446.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10825_HRA SDOH Guidance (CMS-4208-P version 2).docx	Instruction
CMS-10825_HRA SDOH Guidance (CMS-4208-P version 2).docx	Instruction
CMS-10825_HRA SDOH Guidance (CMS-4208-P version 2) REDLINE.pdf REDLINE: Appendix A - List of Screening Instruments	IC Document
CMS-10825_HRA SDOH Guidance (CMS-4208-P version 2) REDLINE.pdf REDLINE: Appendix A - List of Screening Instruments	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.101(f)

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
Instruction					Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13

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: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	13	13
Annual IC Time Burden (Hours)	520	520
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
REDLINE: Appendix A - List of Screening Instruments		01/27/2025

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

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