Information Collection

Laboratory Personnel Report (CLIA) and Supporting Regulations in 42 CFR 493.1 - 493.2001

IC 7865 under ICR 202504-0938-016 · OMB 0938-0151.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-209 Laboratory Personnel Report (CLIA) and Supporting Regulations in 42 CFR 493.1 - 493.2001	Form and Instruction
Form CMS-209 Laboratory Personnel Report (CLIA) Laboratory Personnel Report (CLIA) and Supporting Regulations in 42 CFR 493.1 - 493.2001	Form and Instruction
CMS-209 Laboratory Personnel Report (CLIA) FINAL CMS-209-508 compliant 09.17.24.pdf	Form and Instruction
CMS-209 Laboratory Personnel Report (CLIA) FINAL CMS-209-508 compliant 09.17.24.pdf	Form and Instruction
2024 CMS-209 Revision Crosswalk.docx Crosswalk	IC Document
2024 CMS-209 Revision Crosswalk.docx Crosswalk	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 493.1-493.2001

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-209				Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16,404

Number of Respondents for Small Entity: 8,905

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
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	8,202	-1,380	9,582
Annual IC Time Burden (Hours)	4,101	-690	4,791
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk		05/13/2025

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

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