View Information Collection (IC)

View Information Collection (IC)

IC Title:	Request for Employment Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 407.18 42 CFR 407.17 42 CFR 407.20

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-297 (CMS-L564)	Request for Employment Information	CMS-L564_508_120413 [rev Jan 2017].pdf		Yes	No	Fillable Printable
Form and Instruction	CMS-R-297 (CMS-L564) SP	Solicitud De Informaciobre El Empleo	CMS-L564_SP_508_120413 [rev Jan 2017].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: 15,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	15,000	0	0	0	0	15,000
Annual IC Time Burden (Hours)	5,000	0	0	0	0	5,000
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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