View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 0938-1480	ICR Reference No: 202411-0938-009
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CM
Title: Environmental Health Hazards Checklist Medicare Coverage for Individuals Exposed to Environmental Health Hazards (CMS-10902)
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/02/2025
	Date Received in OIRA: 11/22/2024
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2028	36 Months From Approved
Responses	61	0	0
Time Burden (Hours)	10	0	0
Cost Burden (Dollars)	0	0	0

Annual Cost to Federal Government: $349

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. No

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. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

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: Stephan McKenzie 410 786-1943 stephan.mckenzie@cms.hhs.gov

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