View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

OMB Control No: 0960-0707	ICR Reference No: 202010-0960-008
Status: Historical Active	Previous ICR Reference No: 201706-0960-007
Agency/Subagency: SSA	Agency Tracking No:
Title: Medicare Subsidy Quality Review
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/18/2023
	Date Received in OIRA: 01/28/2021
Terms of Clearance: Prior to renewal, the agency will update the supporting statement question prompt #2 to clarify how the agency adjudicates or further investigates respondents who refuse or fail to respond to this voluntary collection. No later than one year prior to resubmission of this information collection for triannual renewal, the agency will evaluate, and share with OMB the reasoning and results of the evaluation, the capacity to electronically receive and process this form through eSubmit or an alternative electronic submission method.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2026	36 Months From Approved	05/31/2023
Responses	21,350	0	21,350
Time Burden (Hours)	5,631	0	5,631
Cost Burden (Dollars)	0	0	0

Annual Cost to Federal Government: $245,934

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Faye Lipsky 410 965-8783 faye.lipsky@ssa.gov

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