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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Medicaid Drug Rebate Program - Manufacturers and Supporting Regulation at 42 CFR 447.534 (CMS-367)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CMS-367
Medicaid Drug Program Monthly and Quarterly Drug Reporting
DDR Screenshots for PRA 3.31.14.docx
Yes
Yes
Fillable Printable
Other-PRA Disclosure Statement
Manufacturer Stand-Alone PRA 0938-0578 -CMS-367_disclosure_statement - CLEAN.doc
No
Printable Only
Form
CMS-367
Record File Specification
CMS-367 for OMB - Record Specification - CLEAN - 4.1.14.docx
Yes
Yes
Fillable Printable
Instruction
Manufacturer Stand-Alone PRA 0938-0578 - CMS-367_Instructions_to_Labelers - CLEAN.docx
Yes
No
Printable Only
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:
610
Number of Respondents for Small Entity:
100
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
100 %
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
10,370
610
0
320
0
9,440
Annual IC Time Burden (Hours)
156,343
11,895
0
4,736
0
139,712
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Crosswalk - Record Specification
Copy of Form Record Specification Crosswalk.xlsx
04/17/2014
Crosswalk - Instructions for Labelers
Copy of Instructions for Labelers Crosswalk.xlsx
04/17/2014
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.