View Information Collection (IC)

View Information Collection (IC)

IC Title:	Skilled Nursing Facility and Silled Nursing Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.106	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 413.24 42 CFR 413.20

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-2540-10	SKILLED NURSING FACILITY AND SKILLED NURSING FACILITY HEALTH CARE COMPLEX COST REPORT	R5p241F.pdf		Yes	Yes	Fillable Fileable Signable
Instruction			pr2_41.pdf		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: 14,185	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: 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	14,185	0	-1,516	0	0	15,701
Annual IC Time Burden (Hours)	2,865,370	0	-306,232	0	0	3,171,602
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-2540-10 Crosswalk [Added Worksheet]	CMS-2540 Crosswalk.xlsx	07/13/2011
Instruction, Section 4195 - Crosswalk	pr2_4195 Crosswalk.doc	07/14/2011
Instructiom, Section 4105 - Crosswalk	pr2_4100_to_4107 Crosswalk.doc	07/14/2011

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