View Information Collection (IC)

View Information Collection (IC)

IC Title:	Statement of Deficiencies and Plan of Correction	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 and Instruction	CMS-2567	Statement of Deficiencies and Plan of Correction	CMS2567. 06.10.21.pdf		Yes	No	Fillable Printable

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: 65,948	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 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	65,948	0	1,448	0	0	64,500
Annual IC Time Burden (Hours)	1,210,376	0	1,070,626	0	0	139,750
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Change Crosswalk for CMS-2567. 06.10.21 (1).docx	07/13/2021

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