View Information Collection (IC)

View Information Collection (IC)

IC Title:	DDR Product Data Specifications (CMS-367c)	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
Instruction			CMS-367_Instructions_to_Labelers_August 2019_Final.pdf		Yes	Yes	Fillable Fileable
Form	CMS-367c	Product Data	367c_August 2019_Final.pdf		Yes	Yes	Fillable Fileable

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: 743	Number of Respondents for Small Entity: 0

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	743	0	133	0	0	610
Annual IC Time Burden (Hours)	32,321	0	-314	0	0	32,635
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-367c - Track Changes	367c_August 2019_Track Changes.docx	12/12/2019
CMS-367c - Crosswalk	Form Record Specification Crosswalk 367c_August 2019.xlsx	12/12/2019
Instructions - Track Changes	CMS-367_Instructions_to_Labelers_August 2019_Track Changes.docx	12/12/2019
Instructions - Crosswalk	Form Record Specification Crosswalk of Instructions Document December 2019.xlsx	12/12/2019

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