Department of Health and Human Services
Food and Drug Administration
OMB NO: 0910-0001 EXPIRATION DATE: 05/31/2008
RESPS:42,878 HOURS:2,372,556 COSTS(000):$0
FDA Approval to Market a New Drug
FORMS: FDA-2252 FDA-2253 FDA-3331
OMB NO: 0910-0014 EXPIRATION DATE: 05/31/2009
RESPS:1,277,517 HOURS:71,369,525 COSTS(000):$0
Investigational New Drug Regulations
FORMS: 1571 1572
OMB NO: 0910-0016 EXPIRATION DATE: 11/30/2006
RESPS:13 HOURS:31,385 COSTS(000):$560
Submission of Petitions: Food Additive, Color Additive
(Including Labeling), and Generally Recognized as Safe
Affirmation; and Electronic Submission Using FDA Forms 3503 and
3504
FORMS: FDA-3503 FDA-3504
OMB NO: 0910-0021 EXPIRATION DATE: 11/30/2006
RESPS:62 HOURS:211 COSTS(000):$0
Interstate Shellfish Dealer's Certificate
FORMS: FDA-3038
OMB NO: 0910-0025 EXPIRATION DATE: 12/31/2006
RESPS:47,343 HOURS:324,957 COSTS(000):$0
Reporting and Recordkeeping for Electronic Products - General
Requirements
FORMS: FDA-2579 2767 2877 3147
OMB NO: 0910-0027 EXPIRATION DATE: 11/30/2007
RESPS:15 HOURS:6 COSTS(000):$0
Voluntary Registration of Cosmetics Product Establishment
FORMS: FDA-2511
OMB NO: 0910-0030 EXPIRATION DATE: 12/31/2008
RESPS:1,503 HOURS:742 COSTS(000):$0
Cosmetic Product Voluntary Reporting Program - 21 CFR Part 720
FORMS: 2512 2512A 2514
OMB NO: 0910-0032 EXPIRATION DATE: 12/31/2007
RESPS:1,406 HOURS:340,858 COSTS(000):$0
New Animal Drug Application, 21 CFR Part 514
FORMS: 356V
OMB NO: 0910-0037 EXPIRATION DATE: 06/30/2008
RESPS:17,586 HOURS:1,985,108 COSTS(000):$0
Food Canning Establishment Registration, Process Filing and
Recordkeeping for Acidified and Thermally Processed Low-Acid
Foods
FORMS: 2541 2541A 2541C
OMB NO: 0910-0045 EXPIRATION DATE: 12/31/2007
RESPS:75,687 HOURS:189,217 COSTS(000):$0
Registration of Producers of Drugs and Listing of Drugs in
Commercial Distribution
FORMS: NONE
OMB NO: 0910-0046 EXPIRATION DATE: 05/31/2009
RESPS:3,709,134 HOURS:519,279 COSTS(000):$0
Electronic Importer's Entry Notice
FORMS: NONE
OMB NO: 0910-0052 EXPIRATION DATE: 03/31/2009
RESPS:2,875 HOURS:1,533 COSTS(000):$0
Blood Establishment Registration and Product Lising Form FDA 2830
FORMS: FDA-2830
OMB NO: 0910-0053 EXPIRATION DATE: 02/29/2008
RESPS:340 HOURS:2,142 COSTS(000):$0
Radioactive Drug Research Committee (RDRC) Report on Research
Use of Radioactive Drug Study Summary
FORMS: FDA-2914 FDA-2915
OMB NO: 0910-0073 EXPIRATION DATE: 09/30/2007
RESPS:8,254 HOURS:2,833,020 COSTS(000):$1,182
Current Good Manufacturing Practice (CGMP); Quality System (QS)
Regulation
FORMS: NONE
OMB NO: 0910-0078 EXPIRATION DATE: 11/30/2006
RESPS:4,527 HOURS:61,021 COSTS(000):$0
Investigational Device Exemptions Reports and Records - 21 CFR
812
FORMS: NONE
OMB NO: 0910-0114 EXPIRATION DATE: 11/30/2006
RESPS:26 HOURS:461 COSTS(000):$0
Administrative Detention and Banned Medical Devices
FORMS: NONE
OMB NO: 0910-0116 EXPIRATION DATE: 12/31/2008
RESPS:530,829 HOURS:564,678 COSTS(000):$0
Current Good Manufacturing Practices for Blood and Related
Regulations for and Blood Components
FORMS: NONE
OMB NO: 0910-0117 EXPIRATION DATE: 06/30/2008
RESPS:4,527 HOURS:34,622 COSTS(000):$0
New Animal Drugs for Investigational Use
FORMS: 3458
OMB NO: 0910-0119 EXPIRATION DATE: 04/30/2008
RESPS:36,150 HOURS:1,311,157 COSTS(000):$0
Good Laboratory Practice (GLP) Regulations for Nonclinical
Laboratory Studies - 21 CFR Part 58
FORMS: NONE
OMB NO: 0910-0120 EXPIRATION DATE: 05/31/2007
RESPS:26,100 HOURS:359,000 COSTS(000):$0
Premarket Notification Submission 5100(k), Subpart E
FORMS: 3514
OMB NO: 0910-0130 EXPIRATION DATE: 11/30/2007
RESPS:73,000 HOURS:7,300,000 COSTS(000):$0
Protection of Human Subjects; Recordkeeping Requirements for
Institutional Review Boards (IRBs)
FORMS: NONE
OMB NO: 0910-0131 EXPIRATION DATE: 11/30/2006
RESPS:1,800 HOURS:8,100 COSTS(000):$0
Agreement for Shipments of Devices for Sterilization
FORMS: NONE
OMB NO: 0910-0133 EXPIRATION DATE: 07/31/2008
RESPS:14 HOURS:166 COSTS(000):$0
Temporary Marketing Permit Applications
FORMS: NONE
OMB NO: 0910-0138 EXPIRATION DATE: 03/31/2009
RESPS:6 HOURS:3,000 COSTS(000):$0
Reclassification Petitions for Medical Devices
FORMS: FDA-3427 FDA-3428 FDA-3429
OMB NO: 0910-0139 EXPIRATION DATE: 09/30/2008
RESPS:1,174,427 HOURS:798,132 COSTS(000):$0
Current Good Manufacturing Practice; Proposed Amendment of
Certain Requirements for Finished Pharmaceuticals
FORMS: NONE
OMB NO: 0910-0152 EXPIRATION DATE: 12/31/2007
RESPS:36,444,150 HOURS:7,315,661 COSTS(000):$0
Current Good Manufacturing Practice Regulations for Medicated
Feed, 21 CFR Part 225
FORMS: NONE
OMB NO: 0910-0154 EXPIRATION DATE: 12/31/2007
RESPS:180,550 HOURS:157,550 COSTS(000):$0
Good Manufacturing Practice Regulations for Type A Medicated
Articles, 21 CFR Part 226
FORMS: NONE
OMB NO: 0910-0167 EXPIRATION DATE: 07/31/2007
RESPS:1 HOURS:37,343 COSTS(000):$0
Orphan Drug Products
FORMS: NONE
OMB NO: 0910-0183 EXPIRATION DATE: 04/30/2009
RESPS:516 HOURS:6,108 COSTS(000):$0
General Administrative Procedures: Citizen Petitions; Petition
for Reconsideration or Stay of Action; Advisory Opinions
FORMS: NONE
OMB NO: 0910-0184 EXPIRATION DATE: 05/31/2009
RESPS:10 HOURS:200 COSTS(000):$0
Filing Objections and Requests for a Hearing on a Regulation or
Order
FORMS: NONE
OMB NO: 0910-0186 EXPIRATION DATE: 06/30/2009
RESPS:720 HOURS:720 COSTS(000):$0
Irradiation in the Production, Processing and Handling of Food
FORMS: NONE
OMB NO: 0910-0188 EXPIRATION DATE: 07/31/2008
RESPS:1 HOURS:12,854 COSTS(000):$0
Infant Formula Recall Regulations
FORMS: NONE
OMB NO: 0910-0191 EXPIRATION DATE: 05/31/2009
RESPS:1 HOURS:792 COSTS(000):$0
Notice of Participation - 21 CFR 12.45
FORMS: NONE
OMB NO: 0910-0206 EXPIRATION DATE: 08/31/2006
RESPS:6,747 HOURS:20,588 COSTS(000):$0
Request for Samples and Protocols
FORMS: NONE
OMB NO: 0910-0212 EXPIRATION DATE: 12/31/2008
RESPS:1,626 HOURS:2,425 COSTS(000):$0
Regulations Under the Federal Import Milk Act (21 CFR Part 1210)
(formerly Federal Import Milk Act)
FORMS: 1815 1993 1994 1995 1996 1997
OMB NO: 0910-0216 EXPIRATION DATE: 11/30/2007
RESPS:4,603 HOURS:2,302 COSTS(000):$0
Color Additive Requests and Recordkeeping
FORMS: NONE
OMB NO: 0910-0230 EXPIRATION DATE: 04/30/2009
RESPS:410,645 HOURS:7,037,246 COSTS(000):$1,416
Adverse Drug Experience Reporting
FORMS: NONE
OMB NO: 0910-0231 EXPIRATION DATE: 09/30/2007
RESPS:581 HOURS:113,464 COSTS(000):$0
Premarket Approval of Medical Devices - 21 CFR Part 814
FORMS: NONE
OMB NO: 0910-0233 EXPIRATION DATE: 11/30/2007
RESPS:9 HOURS:800 COSTS(000):$0
Patent Term Restoration
FORMS: NONE
OMB NO: 0910-0249 EXPIRATION DATE: 10/31/2008
RESPS:16,625 HOURS:201,875 COSTS(000):$0
FDA Recall Regulations
FORMS: NONE
OMB NO: 0910-0256 EXPIRATION DATE: 03/31/2007
RESPS:40 HOURS:25,968 COSTS(000):$0
Infant Formula Requirements
FORMS: NONE
OMB NO: 0910-0264 EXPIRATION DATE: 11/30/2006
RESPS:20 HOURS:50 COSTS(000):$0
Export of Medical Devices - Foreign Letters of Approval
FORMS: NONE
OMB NO: 0910-0275 EXPIRATION DATE: 11/30/2008
RESPS:1 HOURS:10 COSTS(000):$0
State Enforcement Notification (21 CFR 100.2(d))
FORMS: NONE
OMB NO: 0910-0277 EXPIRATION DATE: 06/30/2008
RESPS:1 HOURS:40 COSTS(000):$0
State Petitions for Exemption from Preemption
FORMS: NONE
OMB NO: 0910-0284 EXPIRATION DATE: 09/30/2006
RESPS:45,528 HOURS:138,114 COSTS(000):$0
Records and Reports Concerning Experience with Approved New
Animal Drugs
FORMS: 1932 1932A 2301
OMB NO: 0910-0291 EXPIRATION DATE: 10/31/2008
RESPS:488,403 HOURS:523,118 COSTS(000):$0
MedWatch: The FDA Medical Products Reporting Program
FORMS: FDA-3500 3500A
OMB NO: 0910-0297 EXPIRATION DATE: 12/31/2006
RESPS:3,231 HOURS:969 COSTS(000):$0
User Fee Cover Sheet
FORMS: 3397
OMB NO: 0910-0298 EXPIRATION DATE: 03/31/2007
RESPS:6 HOURS:288 COSTS(000):$0
Food Additives; Threshold of Regulation for Substances Used in
Food-Contact Articles
FORMS: NONE
OMB NO: 0910-0302 EXPIRATION DATE: 05/31/2007
RESPS:62 HOURS:592,166 COSTS(000):$0
Human Tissue Intended for Transplantation
FORMS: NONE
OMB NO: 0910-0303 EXPIRATION DATE: 07/31/2008
RESPS:4,500 HOURS:270,000 COSTS(000):$0
Electronic Records: Electronic Signatures
FORMS: NONE
OMB NO: 0910-0308 EXPIRATION DATE: 07/31/2008
RESPS:22,324 HOURS:493,522 COSTS(000):$0
Adverse Experience Reporting for Licensed Biological Product;
and General Records
FORMS: NONE
OMB NO: 0910-0309 EXPIRATION DATE: 03/31/2007
RESPS:36,000,000 HOURS:3,219,936 COSTS(000):$19,491
Mammography Facilities, Standards, and Lay Summaries for Patients
FORMS: FDA-3422
OMB NO: 0910-0320 EXPIRATION DATE: 09/30/2007
RESPS:191 HOURS:553 COSTS(000):$0
Request for Information from U.S. Processors that Export to the
European Community
FORMS: NONE
OMB NO: 0910-0322 EXPIRATION DATE: 12/31/2006
RESPS:10,748 HOURS:210,182 COSTS(000):$0
21 CFR 25-Enviornmental Impact Considerations
FORMS: NONE
OMB NO: 0910-0325 EXPIRATION DATE: 11/30/2008
RESPS:2 HOURS:8,320 COSTS(000):$0
Extralabel Drug Use in Animals
FORMS: NONE
OMB NO: 0910-0330 EXPIRATION DATE: 07/31/2008
RESPS:71 HOURS:1,420 COSTS(000):$0
Premarket Notification for a New Dietary Ingredient
FORMS: NONE
OMB NO: 0910-0331 EXPIRATION DATE: 12/31/2006
RESPS:2,500 HOURS:1,875 COSTS(000):$0
Food Labeling: Notification Procedures for Statements on Dietary
Supplements
FORMS: NONE
OMB NO: 0910-0332 EXPIRATION DATE: 12/31/2008
RESPS:108 HOURS:10,038 COSTS(000):$0
Medical Devices; Humanitarian Use Devices; 21 CFR Part 814 -
Subpart H
FORMS: NONE
OMB NO: 0910-0337 EXPIRATION DATE: 12/31/2006
RESPS:1,292 HOURS:71 COSTS(000):$0
Medicated Fee Mill License Application
FORMS: 3448
OMB NO: 0910-0338 EXPIRATION DATE: 09/30/2008
RESPS:14,613 HOURS:335,088 COSTS(000):$0
General Licensing Provisions: Biologics License Application,
Changes to an Approved Application, Labeling, Revocation and
Suspension, and Forms FDA 356h & 2567
FORMS: FDA-2567 FDA-356H
OMB NO: 0910-0339 EXPIRATION DATE: 05/31/2007
RESPS:400 HOURS:5,600 COSTS(000):$0
Substances Prohibited from Use in Animal Food or Feed; Animal
Proteins Prohibited in Ruminant Feed
FORMS: NONE
OMB NO: 0910-0340 EXPIRATION DATE: 06/30/2008
RESPS:39,932 HOURS:120,578 COSTS(000):$0
Over-the-Counter Human Drugs; Labeling Requirements
FORMS: NONE
OMB NO: 0910-0341 EXPIRATION DATE: 10/31/2006
RESPS:924 HOURS:157 COSTS(000):$0
FDA Safety Alert/Public Health Advisory Readership Survey
FORMS: NONE
OMB NO: 0910-0342 EXPIRATION DATE: 05/31/2009
RESPS:60 HOURS:9,900 COSTS(000):$0
Substances Generally Recognized as Safe: Notification Procedure
FORMS: NONE
OMB NO: 0910-0345 EXPIRATION DATE: 09/30/2008
RESPS:1 HOURS:1,401 COSTS(000):$0
2005 Food Safety Survey
FORMS: NONE
OMB NO: 0910-0354 EXPIRATION DATE: 12/31/2006
RESPS:5,850 HOURS:627,075 COSTS(000):$9,406
Procedures for the Safe Processing and Importing of Fish and
Fishery Products; 21 CFR Part 123
FORMS: NONE
OMB NO: 0910-0356 EXPIRATION DATE: 03/31/2007
RESPS:860 HOURS:544,036 COSTS(000):$0
Substantial Evidence of Effectiveness of New Animal Drugs
FORMS: NONE
OMB NO: 0910-0359 EXPIRATION DATE: 04/30/2008
RESPS:625 HOURS:6,250 COSTS(000):$0
Medical Devices; Reports of Corrections and Removals
FORMS: NONE
OMB NO: 0910-0360 EXPIRATION DATE: 05/31/2008
RESPS:6,000 HOURS:1,800 COSTS(000):$0
Customer/Partner Service Surveys - (Extension)
FORMS: NONE
OMB NO: 0910-0363 EXPIRATION DATE: 11/30/2008
RESPS:1,880,521 HOURS:120,184 COSTS(000):$0
Veterinary Feed Directive
FORMS: NONE
OMB NO: 0910-0370 EXPIRATION DATE: 09/30/2007
RESPS:557 HOURS:1,762 COSTS(000):$0
Specific Requirements on the Content and Format of Labeling for
Human Prescription Drugs; Addition of Geriatric Use Subsection
FORMS: NONE
OMB NO: 0910-0374 EXPIRATION DATE: 09/30/2008
RESPS:3 HOURS:1,153 COSTS(000):$0
Guidance for Industry: Notification of a Health Claim or
Nutrient Content Claim Based on an Authoritative Statement of a
Scientific Body
FORMS: NONE
OMB NO: 0910-0375 EXPIRATION DATE: 12/31/2007
RESPS:11 HOURS:10,860 COSTS(000):$0
Medical Devices; Third Party Review Under FDAMA
FORMS: NONE
OMB NO: 0910-0378 EXPIRATION DATE: 04/30/2008
RESPS:210 HOURS:14,622 COSTS(000):$0
Medical Devices, Third Party Premarket Submission Review and
Quality System Inspections Under U.S./E.C. MRA
FORMS: NONE
OMB NO: 0910-0381 EXPIRATION DATE: 05/31/2007
RESPS:509,579 HOURS:1,594,269 COSTS(000):$16,800
Food Labeling Regulations
FORMS: NONE
OMB NO: 0910-0387 EXPIRATION DATE: 04/30/2008
RESPS:1 HOURS:41,850 COSTS(000):$0
Medical Devices Registration and Listing
FORMS: 2891 2891A 2892
OMB NO: 0910-0389 EXPIRATION DATE: 08/31/2008
RESPS:114 HOURS:8,720 COSTS(000):$0
Guidance for Industry: Fast Track Drug Development Programs -
Designation, Development, and Application Review
FORMS: NONE
OMB NO: 0910-0390 EXPIRATION DATE: 12/31/2008
RESPS:157 HOURS:2,114 COSTS(000):$0
Dissemination of Information on Unapproval/New Uses for Marketed
Drugs, Biologics, and Devices
FORMS: NONE
OMB NO: 0910-0393 EXPIRATION DATE: 08/31/2008
RESPS:1,100,000 HOURS:4,248 COSTS(000):$0
Prescription Drug Product Labeling; Medication Guide Requirements
FORMS: NONE
OMB NO: 0910-0396 EXPIRATION DATE: 04/30/2009
RESPS:1 HOURS:18,750 COSTS(000):$0
Financial Disclosure by Clinical Investigators
FORMS: 3454 3455
OMB NO: 0910-0409 EXPIRATION DATE: 10/31/2008
RESPS:2 HOURS:4,000 COSTS(000):$0
Regs. for In Vivo Radiopharmaceuticals Used for Diagnosis nd
Monitoring - Final Rule
FORMS: NONE
OMB NO: 0910-0428 EXPIRATION DATE: 01/31/2009
RESPS:25 HOURS:25 COSTS(000):$0
Record Retention Requirements for the Soy Protein/CHD Health
Claim
FORMS: NONE
OMB NO: 0910-0429 EXPIRATION DATE: 03/31/2009
RESPS:3,642 HOURS:49,004 COSTS(000):$0
Guidance for Industry on Formal Meetings with Sponsors and
Applicants for PDUFA Products
FORMS: 1571 1572 356H
OMB NO: 0910-0430 EXPIRATION DATE: 04/30/2009
RESPS:11 HOURS:88 COSTS(000):$0
Guidance for Industry on Formal Dispute Resolutions; Appeals
Above the Division Level
FORMS: 1571 356H
OMB NO: 0910-0432 EXPIRATION DATE: 02/28/2009
RESPS:2 HOURS:1,082 COSTS(000):$0
Medical Device Recall Authority
FORMS: NONE
OMB NO: 0910-0433 EXPIRATION DATE: 03/31/2007
RESPS:65 HOURS:1,560 COSTS(000):$0
Postmarketing Studies for Human Drugs and Licensed Biological
Products; Status Report
FORMS: NONE
OMB NO: 0910-0435 EXPIRATION DATE: 08/31/2006
RESPS:102,261,312 HOURS:10,634,432 COSTS(000):$0
Prescription Drug Marketing Act of 1987; Policies, Requirements,
and Administrative Procedures
FORMS: NONE
OMB NO: 0910-0437 EXPIRATION DATE: 05/31/2009
RESPS:122,325 HOURS:138,271 COSTS(000):$0
Medical Devices; Medical Device Reporting; Manufacturer
reporting; importer reporting, user facility reporting,
distributor reporting
FORMS: FDA-3417 FDA-3419
OMB NO: 0910-0439 EXPIRATION DATE: 07/31/2009
RESPS:10 HOURS:140 COSTS(000):$0
Aluminum in Large and Small Volume Parenterals Used in Total
Parenteral Nutrition
FORMS: NONE
OMB NO: 0910-0442 EXPIRATION DATE: 04/30/2008
RESPS:1,481,939 HOURS:3,407,184 COSTS(000):$0
Medical Devices; Device Tracking (Amended)
FORMS: NONE
OMB NO: 0910-0445 EXPIRATION DATE: 12/31/2006
RESPS:164 HOURS:46,576 COSTS(000):$0
Guidance for Industry: Submitting and Reviewing Complete
Responses to Clinical Holds
FORMS: NONE
OMB NO: 0910-0448 EXPIRATION DATE: 01/31/2007
RESPS:600 HOURS:600 COSTS(000):$0
Adoption of FDA Food Code by Local, State and Tribal Governments
FORMS: NONE
OMB NO: 0910-0449 EXPIRATION DATE: 12/31/2006
RESPS:138 HOURS:5,778 COSTS(000):$0
Postmarket Surveillance of Medical Devices
FORMS: NONE
OMB NO: 0910-0450 EXPIRATION DATE: 02/28/2007
RESPS:84 HOURS:33 COSTS(000):$0
Guidance for Industry on How to Use E-Mail to Submit a Notice of
Intent to Slaughter for Human Food Purposes
FORMS: FDA-3488
OMB NO: 0910-0452 EXPIRATION DATE: 03/31/2007
RESPS:168 HOURS:116 COSTS(000):$0
Guidance for Indusry on How to Use E-Mail to Submit a Request
for a Meeting or Teleconference to the Office of New Animal Drug
Evaluation
FORMS: 3489
OMB NO: 0910-0453 EXPIRATION DATE: 02/28/2007
RESPS:324 HOURS:262 COSTS(000):$0
Guidance for Industry on How to Use E-Mail to Submit a Notice of
Final Disposition of Animals Not Intended for Immediate Slaughter
FORMS: FDA-3487
OMB NO: 0910-0454 EXPIRATION DATE: 03/31/2007
RESPS:140 HOURS:70 COSTS(000):$0
Guidance for Industry on How to Use E-Mail Submit Information to
the Center for Veterinary Medicine
FORMS: 3538
OMB NO: 0910-0456 EXPIRATION DATE: 12/31/2006
RESPS:50 HOURS:156 COSTS(000):$0
Infectious Disease Issues in Xenotransplantation
FORMS: NONE
OMB NO: 0910-0458 EXPIRATION DATE: 03/31/2007
RESPS:33,922 HOURS:67,844 COSTS(000):$0
Biological Products: Reporting of Biological Product Deviations
in Manufacturing
FORMS: 3486
OMB NO: 0910-0459 EXPIRATION DATE: 05/31/2007
RESPS:38,514 HOURS:177,165 COSTS(000):$0
Information Program on Clinical Trials for Serious and
Life-Threatening Diseases: Maintaining a Databank
FORMS: NONE
OMB NO: 0910-0466 EXPIRATION DATE: 07/31/2007
RESPS:15,035 HOURS:360,930 COSTS(000):$0
Hazard Analysis and Critical Control Point (HACCP) Procedures
for the Safe and Sanitary Processing of Juice (21 CFR Part 120)
FORMS: NONE
OMB NO: 0910-0469 EXPIRATION DATE: 07/31/2007
RESPS:1,370 HOURS:1,005 COSTS(000):$0
Human Cells, Tissues, and Cellular and Tissue-Based Products;
Establishment Registration and Listing
FORMS: FDA-3356
OMB NO: 0910-0470 EXPIRATION DATE: 09/30/2007
RESPS:334 HOURS:4,723 COSTS(000):$0
Special Protocol Assessment Guidance
FORMS: NONE
OMB NO: 0910-0471 EXPIRATION DATE: 09/30/2007
RESPS:2,800 HOURS:2,772 COSTS(000):$0
Adverse Event Pilot Program for Medical Devices
FORMS: NONE
OMB NO: 0910-0482 EXPIRATION DATE: 06/30/2008
RESPS:2,065 HOURS:43,214 COSTS(000):$0
Exports: Notification and Recordkeeping Requirements
FORMS: NONE
OMB NO: 0910-0485 EXPIRATION DATE: 06/30/2008
RESPS:2,320,385 HOURS:3,503,120 COSTS(000):$0
Medical Device Labeling Regulations
FORMS: NONE
OMB NO: 0910-0491 EXPIRATION DATE: 05/31/2009
RESPS:195 HOURS:98 COSTS(000):$0
Emergency Shortages Data Collection System (formerly Emergency
Medical Device Shortage Program Survey)
FORMS: NONE
OMB NO: 0910-0495 EXPIRATION DATE: 12/31/2008
RESPS:126 HOURS:15,985 COSTS(000):$23,500
Food Additives; Food Contact Substances Notification System
FORMS: 3479 3480
OMB NO: 0910-0497 EXPIRATION DATE: 11/30/2007
RESPS:2,574 HOURS:4,252 COSTS(000):$0
Focus Groups as Used by the Food and Drug Administration
FORMS: NONE
OMB NO: 0910-0498 EXPIRATION DATE: 03/31/2009
RESPS:14,213 HOURS:21,170 COSTS(000):$0
Export Certificates for FDA Regulated Products under U.S.C.
Sections 801(e) and 802
FORMS: 3613 3613A 3613B 3613C 3613D 3613E
OMB NO: 0910-0500 EXPIRATION DATE: 11/30/2007
RESPS:6,000 HOURS:3,000 COSTS(000):$0
Generic FDA Rapid Response Surveys
FORMS: NONE
OMB NO: 0910-0502 EXPIRATION DATE: 10/31/2006
RESPS:421,361 HOURS:521,831 COSTS(000):$0
Registration of Food Facilities Under the Public Health Security
and Bioterrorism Preparedness and Response Act of 2002
FORMS: FDA-3537 FDA-3537A
OMB NO: 0910-0508 EXPIRATION DATE: 12/31/2006
RESPS:3,000 HOURS:3,000 COSTS(000):$0
FY 2003 MDUFMA Small Business Qualification Certification (Form
FDA 3602)
FORMS: 3602
OMB NO: 0910-0509 EXPIRATION DATE: 12/31/2006
RESPS:50 HOURS:150 COSTS(000):$0
Establishing a List of U.S. Dairy Producers for Export to Chile
FORMS: NONE
OMB NO: 0910-0510 EXPIRATION DATE: 11/30/2006
RESPS:25 HOURS:2,550 COSTS(000):$0
Medical Devices; Inspection by Accredited Persons Program Under
the Medical Device User Fee and Modernization Act of 2002
(MDUFMA)
FORMS: NONE
OMB NO: 0910-0511 EXPIRATION DATE: 11/30/2006
RESPS:5,000 HOURS:1,500 COSTS(000):$0
Medical Device User Fee Cover Sheet - FDA Form 3601
FORMS: FDA-3601
OMB NO: 0910-0513 EXPIRATION DATE: 10/31/2006
RESPS:481 HOURS:499,805 COSTS(000):$0
Applications for FDA Approval to Market a New Drug: Patient
Listing Requirements and Application of 30-month Stays on
Approval of Abbreviated New Drug Applications Certifying That...
FORMS: 3542 3542(A)
OMB NO: 0910-0515 EXPIRATION DATE: 11/30/2006
RESPS:307,600 HOURS:615,200 COSTS(000):$171,700
Food Labeling: Trans Fatty Acids in Nutrition Labeling
FORMS: NONE
OMB NO: 0910-0516 EXPIRATION DATE: 10/31/2006
RESPS:5,000 HOURS:1,500 COSTS(000):$0
Impact of Risk Management Programs on the Practice of Pharmacy -
Survey
FORMS: NONE
OMB NO: 0910-0518 EXPIRATION DATE: 06/30/2007
RESPS:125 HOURS:10,000 COSTS(000):$0
Guidance for Industry: Continuous Marketing Applications: Pilot
2 Scientific Feedback and Interactions During Development of
Fast Track Products Under PDUFA
FORMS: NONE
OMB NO: 0910-0519 EXPIRATION DATE: 09/30/2007
RESPS:120 HOURS:480 COSTS(000):$0
Control of Communicable Diseases; Requests for Exemptions from
the Restrictions on African Rodents, Prairie Dogs, and Certain
Other Animals
FORMS: NONE
OMB NO: 0910-0520 EXPIRATION DATE: 10/31/2006
RESPS:6,891,625 HOURS:2,836,781 COSTS(000):$6,268
Prior Notice of Imported Food Shipments
FORMS: 3540
OMB NO: 0910-0521 EXPIRATION DATE: 01/31/2007
RESPS:5 HOURS:70,550 COSTS(000):$0
Assessment of the Effects of Antimicrobial Drug Residues from
Food of Animal Origin on the Human Intestinal Flora
FORMS: NONE
OMB NO: 0910-0523 EXPIRATION DATE: 02/28/2007
RESPS:28 HOURS:672 COSTS(000):$0
Product Jurisdiction: Assignment of Agency Component for Review
of Premarket Applications
FORMS: NONE
OMB NO: 0910-0524 EXPIRATION DATE: 02/28/2007
RESPS:100 HOURS:20 COSTS(000):$0
Draft Guidance for Industry: How to Use E-Mail to Submit a Study
Protocol
FORMS: 3536
OMB NO: 0910-0528 EXPIRATION DATE: 03/31/2007
RESPS:1,158 HOURS:579 COSTS(000):$0
Guidance for Industry - Reports on the Status of Postmarketing
Studies - Implementation of Section 130 of the Food and Drug
Administration Modernization Act of 1997
FORMS: NONE
OMB NO: 0910-0530 EXPIRATION DATE: 11/30/2006
RESPS:9,200 HOURS:52,344 COSTS(000):$0
Requirements for Submission of Labeling for Human Prescription
Drugs and Biologics in Electronic Format
FORMS: NONE
OMB NO: 0910-0537 EXPIRATION DATE: 02/28/2007
RESPS:41,753,827 HOURS:1,777,550 COSTS(000):$0
Bar Code Label Requirements for Human Drug Products and
Biological Products (Final Rule)
FORMS: NONE
OMB NO: 0910-0538 EXPIRATION DATE: 03/31/2007
RESPS:31,555 HOURS:1,023,310 COSTS(000):$0
Supplements and Other Changes to an Approved Application - Final
Rule
FORMS: NONE
OMB NO: 0910-0539 EXPIRATION DATE: 12/31/2007
RESPS:69 HOURS:69 COSTS(000):$0
Animal Drug User Fee Cover Sheet
FORMS: 3546
OMB NO: 0910-0540 EXPIRATION DATE: 12/31/2007
RESPS:30 HOURS:60 COSTS(000):$0
Guidance for Industry: Animal Drug User Fees and Fee Waivers and
Reductions
FORMS: NONE
OMB NO: 0910-0541 EXPIRATION DATE: 06/30/2007
RESPS:147 HOURS:147 COSTS(000):$0
Preparing a Claim of Categorical Exclusion or an Environmental
Assessment for Submission to the Center for Food Safety and
Applied Nutrition
FORMS: NONE
OMB NO: 0910-0543 EXPIRATION DATE: 05/31/2007
RESPS:1,274,272 HOURS:866,240 COSTS(000):$0
Eligibility Determination for Donors of Human Cells, Tissues,
and Cellular and Tissue-Based Products (HCT/Ps)
FORMS: NONE
OMB NO: 0910-0545 EXPIRATION DATE: 09/30/2007
RESPS:4,600 HOURS:1,083 COSTS(000):$0
Health and Diet Survey -- 2004 Supplement
FORMS: NONE
OMB NO: 0910-0546 EXPIRATION DATE: 11/30/2006
RESPS:6 HOURS:13,000 COSTS(000):$0
Food Additive Petitions, 21 CFR Part 571, Center for Veterinary
Medicine
FORMS: NONE
OMB NO: 0910-0548 EXPIRATION DATE: 08/31/2006
RESPS:1 HOURS:71 COSTS(000):$0
Requirements for Collection of Data Relating to the Prevention
of Medical Gas Mix-ups at Health Care Facilities Survey
FORMS: NONE
OMB NO: 0910-0549 EXPIRATION DATE: 06/30/2008
RESPS:1 HOURS:1 COSTS(000):$0
Irradiation in the Production, Processing and Handling of Food
FORMS: NONE
OMB NO: 0910-0551 EXPIRATION DATE: 02/29/2008
RESPS:100 HOURS:100 COSTS(000):$0
Application for Participation in the Medical Device Fellowship
Program; Form FDA 3608
FORMS: FDA-3608
OMB NO: 0910-0553 EXPIRATION DATE: 10/31/2007
RESPS:1,742 HOURS:34,840 COSTS(000):$0
Use of Symbols on Labels and in Labeling of In Vitro Diagnostic
Devices Intended for Professional Use
FORMS: NONE
OMB NO: 0910-0555 EXPIRATION DATE: 11/30/2007
RESPS:190 HOURS:27,740 COSTS(000):$0
SPresubmission Conferences - Final Rule
FORMS: NONE
OMB NO: 0910-0557 EXPIRATION DATE: 12/31/2007
RESPS:80 HOURS:6,400 COSTS(000):$0
Guidance for Industry - Pharmacogenomic Data Submissions
FORMS: NONE
OMB NO: 0910-0558 EXPIRATION DATE: 12/31/2007
RESPS:15,978 HOURS:7,669 COSTS(000):$0
Infant Feeding Practices Study II
FORMS: NONE
OMB NO: 0910-0559 EXPIRATION DATE: 11/30/2007
RESPS:23,731 HOURS:283,400 COSTS(000):$0
Current Good Tissue Practice for Human Cell, Tissue, and
Cellular and Tissue-Based Product Establishments; Inspection and
Enforcement
FORMS: NONE
OMB NO: 0910-0560 EXPIRATION DATE: 02/29/2008
RESPS:707,672 HOURS:5,359,000 COSTS(000):$6,646
Recordkeeping and Records Access Requirements for Food Facilities
FORMS: NONE
OMB NO: 0910-0562 EXPIRATION DATE: 05/31/2008
RESPS:652 HOURS:2,998 COSTS(000):$32
Channels of Trade Policy for Commodities with Residues of
Pesticide Chemicals for Which Tolerances Have Been Rovoked,
Suspended, or Modified by the EPA
FORMS: NONE
OMB NO: 0910-0563 EXPIRATION DATE: 05/31/2008
RESPS:30 HOURS:790 COSTS(000):$0
Guidance for Industry: Formal Dispute Resolution; Scientific and
Technical Issues Related to Pharmaceutical Current Good
Manufacturing Practice
FORMS: NONE
OMB NO: 0910-0564 EXPIRATION DATE: 05/31/2008
RESPS:300 HOURS:54,000 COSTS(000):$0
Performance Standard for Diagnostic X-Ray Systems and Their
Major Components
FORMS: NONE
OMB NO: 0910-0565 EXPIRATION DATE: 08/31/2008
RESPS:2,880 HOURS:1,827 COSTS(000):$0
Experimental Study of Health Claims on Food Packages
FORMS: NONE
OMB NO: 0910-0566 EXPIRATION DATE: 06/30/2008
RESPS:2 HOURS:60 COSTS(000):$0
Dispute Resolution Procedures for Science Based Decisions on
Products Regulated by the CVM
FORMS: NONE
OMB NO: 0910-0567 EXPIRATION DATE: 07/31/2008
RESPS:5,060 HOURS:845 COSTS(000):$0
Allergen Labeling of Food Products Consumer Preference Survey
and Experimental Study on Allergen Labeling of Food Products
FORMS: NONE
OMB NO: 0910-0569 EXPIRATION DATE: 08/31/2008
RESPS:15 HOURS:1,500 COSTS(000):$0
Requests for Inspection by an Accredited Person under the
Inspection by Accredited Persons Program
FORMS: NONE
OMB NO: 0910-0570 EXPIRATION DATE: 12/31/2008
RESPS:10,000 HOURS:2,731 COSTS(000):$0
Experimental Study of Carbohydrate Content Claims on Food Labels
FORMS: NONE
OMB NO: 0910-0571 EXPIRATION DATE: 05/31/2008
RESPS:900 HOURS:4,500 COSTS(000):$0
Guidance for Requesting an Extension to Use Existing Label Stock
After The Trans Fat Labeling Effective Date of January 1, 2006
FORMS: NONE
OMB NO: 0910-0572 EXPIRATION DATE: 01/31/2009
RESPS:1,911 HOURS:501,383 COSTS(000):$0
Requirements on Content and Format of Labeling for Human
Prescription Drug and Biological Products, Final Rule
FORMS: NONE
OMB NO: 0910-0575 EXPIRATION DATE: 01/31/2009
RESPS:18 HOURS:265 COSTS(000):$0
Waivers of Invivo Demonstration of Bioequivalence of Animal
Drugs in Soluble Powder Oral Dosage Form and Type a Medicated
Articles
FORMS: NONE
OMB NO: 0910-0577 EXPIRATION DATE: 01/31/2009
RESPS:300 HOURS:30 COSTS(000):$0
Reprocessed Single-Use Device Labeling
FORMS: NONE
OMB NO: 0910-0578 EXPIRATION DATE: 03/31/2009
RESPS:36,500,000 HOURS:5,400,000 COSTS(000):$0
Voluntary Hazard Analysis and Critical Control Point Manuals for
Operators and Regulators of Retail and Food Service
Establishments
FORMS: NONE
OMB NO: 0910-0579 EXPIRATION DATE: 03/31/2009
RESPS:144 HOURS:144 COSTS(000):$0
Research Study Complaint Form
FORMS: NONE
OMB NO: 0910-0580 EXPIRATION DATE: 03/31/2009
RESPS:1,007 HOURS:1,194 COSTS(000):$0
The Mammography Quality Standards Act Final Regulations:
Modifications and Aditions to Policy Guidance Help System #9
FORMS: NONE
OMB NO: 0910-0581 EXPIRATION DATE: 03/31/2009
RESPS:1,148 HOURS:1,795 COSTS(000):$0
Guidance for Industry: Clinical Trial Sponsors on the
Establishment and Operation of Clinical Trial Data Monitoring
Committees
FORMS: NONE
OMB NO: 0910-0582 EXPIRATION DATE: 09/30/2006
RESPS:600 HOURS:2,400 COSTS(000):$0
Guidance on Informed Consent for in Vitro Diagnostic Studies
Using Leftover Human Specimens that are not Individually
Identifiable
FORMS: NONE
OMB NO: 0910-0583 EXPIRATION DATE: 04/30/2009
RESPS:20 HOURS:400 COSTS(000):$0
Recommendations for Early Food Safety Evaluation of New
Non-Pesticidal Proteins Produced by New Plan Varieties Intended
for Food Use
FORMS: NONE
OMB NO: 0910-0584 EXPIRATION DATE: 12/31/2006
RESPS:20 HOURS:200 COSTS(000):$0
Emergency Request: Guidance for Reagents for Detection of
Specific Novel Influenza A Viruses
FORMS: NONE
OMB NO: 0910-0586 EXPIRATION DATE: 11/30/2006
RESPS:450 HOURS:900 COSTS(000):$0
Medical Devices; Exception from General Requirements for
Informed Consent
FORMS: NONE
OMB NO: 0910-0588 EXPIRATION DATE: 05/31/2009
RESPS:300 HOURS:100 COSTS(000):$0
Survey of Healthcare Practitioners Regarding Their Preferences
for Public Health Notifications
FORMS: NONE
OMB NO: 0910-0591 EXPIRATION DATE: 05/31/2009
RESPS:1 HOURS:156 COSTS(000):$0
Evaluation of Consumer-Friendly Formats for Brief Summary in
Direct-to-Consumer (DTC) Print Advertisements for Prescription
Drugs: Study 1
FORMS: NONE
OMB NO: 0910-0593 EXPIRATION DATE: 12/31/2006
RESPS:96 HOURS:48 COSTS(000):$0
MedWatch - The FDA Safety Information and Adverse Event
Reporting Program; Proposal to Survey MedWatch Partners
Organizations - Survey
FORMS: NONE
SUBAGENCY TOTALS
ACTIVE ANNUAL ANNUAL ANNUAL
REPORTS RESPONSES HOURS COSTS($000)
167 278,535,518 152,778,424 $257,001
Health Services Administration
OMB NO: 0915-0034 EXPIRATION DATE: 08/31/2006
RESPS:16,400 HOURS:1,652 COSTS(000):$0
Health Education Assistance Loan (HEAL) Program: Forms
FORMS: HRSA-504
OMB NO: 0915-0036 EXPIRATION DATE: 09/30/2008
RESPS:20,960 HOURS:3,767 COSTS(000):$7
Health Education Assistance Loan (HEAL) Program: Lender's
Application for Insurance Claim Form and Request for Collection
Assistance Form
FORMS: NONE
OMB NO: 0915-0043 EXPIRATION DATE: 12/31/2006
RESPS:10,070 HOURS:5,055 COSTS(000):$0
Health Education Assistance Loan (HEAL)
FORMS: HRSA-502-1
OMB NO: 0915-0044 EXPIRATION DATE: 03/31/2009
RESPS:3,977 HOURS:4,408 COSTS(000):$0
Health Professions Student Loan and Nursing Student Loan
Programs - Forms
FORMS: HRSA-501 HRSA-519
OMB NO: 0915-0047 EXPIRATION DATE: 10/31/2008
RESPS:133,075 HOURS:52,690 COSTS(000):$0
Health Professions Student Loan (HPSL) Program and Nursing
Student Loan (NSL) Program: Administrative Requirements (Regs. &
Policy)
FORMS: NONE
OMB NO: 0915-0060 EXPIRATION DATE: 08/31/2006
RESPS:1,805 HOURS:101,531 COSTS(000):$27
HRSA Competing Training Grant Application
FORMS: PHS-6025-1
OMB NO: 0915-0061 EXPIRATION DATE: 01/31/2008
RESPS:1,550 HOURS:33,325 COSTS(000):$0
The Uniform Progress Reports (UPR) for HRSA Continuation
Training Grants
FORMS: NONE
OMB NO: 0915-0077 EXPIRATION DATE: 04/30/2009
RESPS:29,208 HOURS:33,040 COSTS(000):$0
Uncompensated Services Assurance Report
FORMS: HRSA-710
OMB NO: 0915-0099 EXPIRATION DATE: 11/30/2006
RESPS:10 HOURS:12 COSTS(000):$0
Grants for Hospital Construction and Modernization - Federal
Right of Recovery and Waiver of Recovery
FORMS: NONE
OMB NO: 0915-0108 EXPIRATION DATE: 01/31/2007
RESPS:280,793 HOURS:74,918 COSTS(000):$0
Health Education Assistance Loan (HEAL) Program Regs.
FORMS: NONE
OMB NO: 0915-0126 EXPIRATION DATE: 05/31/2007
RESPS:3,319,694 HOURS:293,589 COSTS(000):$13,508
National Practitioner Data Bank for Adverse Information on
Physicians and Other Health Care Practitioners: Regulations and
Forms
FORMS: NONE
OMB NO: 0915-0127 EXPIRATION DATE: 08/31/2007
RESPS:1,500 HOURS:2,163 COSTS(000):$0
The National Health Service Corps (NHSC) Loan Repayment Program
FORMS: HRSA-873
OMB NO: 0915-0140 EXPIRATION DATE: 11/30/2007
RESPS:9,200 HOURS:54,000 COSTS(000):$0
The Nursing Education Loan Repayment Program
FORMS: NONE
OMB NO: 0915-0142 EXPIRATION DATE: 10/31/2008
RESPS:140 HOURS:5,500 COSTS(000):$0
Application for Certification as a Federally Qualified Health
Center Look-Alike
FORMS: NONE
OMB NO: 0915-0146 EXPIRATION DATE: 11/30/2006
RESPS:3,100 HOURS:3,100 COSTS(000):$8
Application for Participation in the National Health Service
Corps Scholarship Program
FORMS: HRSA-856
OMB NO: 0915-0149 EXPIRATION DATE: 12/31/2006
RESPS:450 HOURS:10,575 COSTS(000):$0
Scholarships for Disadvantaged Students (SDS) Graduate Survey
FORMS: NONE
OMB NO: 0915-0150 EXPIRATION DATE: 09/30/2006
RESPS:94 HOURS:94 COSTS(000):$0
Faculty Loan Repayment Program Application
FORMS: HRSA-535
OMB NO: 0915-0151 EXPIRATION DATE: 06/30/2008
RESPS:125 HOURS:2,500 COSTS(000):$0
Ryan White CARE Act Dental Reimbursement Program
FORMS: NONE
OMB NO: 0915-0157 EXPIRATION DATE: 08/31/2007
RESPS:559,762 HOURS:84,057 COSTS(000):$0
Organ Procurement and Transplantation Network and Scientific
Registry of Transplant Recipients Data System
FORMS: NONE
OMB NO: 0915-0172 EXPIRATION DATE: 05/31/2009
RESPS:59 HOURS:18,064 COSTS(000):$0
Maternal and Child Health Services Block Grant Report
FORMS: NONE
OMB NO: 0915-0174 EXPIRATION DATE: 08/31/2006
RESPS:125 HOURS:125 COSTS(000):$0
Loan Information System Records for the DHHS DHUD Hospital
Mortgage Insurance, Guarantee, and Direct Loan Program
FORMS: HRSA-906
OMB NO: 0915-0176 EXPIRATION DATE: 11/30/2006
RESPS:8 HOURS:134 COSTS(000):$0
Drug Pricing Program Reporting Requirements
FORMS: NONE
OMB NO: 0915-0179 EXPIRATION DATE: 06/30/2007
RESPS:700 HOURS:700 COSTS(000):$0
Deferment Request Form for the National Health Service Corps
Scholarship Program
FORMS: NONE
OMB NO: 0915-0184 EXPIRATION DATE: 12/31/2007
RESPS:36,457 HOURS:19,459 COSTS(000):$0
Organ Procurement and Transplantation Network
FORMS: NONE
OMB NO: 0915-0193 EXPIRATION DATE: 05/31/2007
RESPS:1,045 HOURS:27,090 COSTS(000):$14,000
Uniform Data System
FORMS: NONE
OMB NO: 0915-0204 EXPIRATION DATE: 05/31/2007
RESPS:282 HOURS:71 COSTS(000):$2
HEAL Program: Physician's Certification of Borrower's Total and
Permanent Disability
FORMS: 539
OMB NO: 0915-0208 EXPIRATION DATE: 12/31/2006
RESPS:308 HOURS:26 COSTS(000):$0
Professional Training and Information Questionnaire
FORMS: HRSA-551 HRSA-552
OMB NO: 0915-0212 EXPIRATION DATE: 04/30/2009
RESPS:52,050 HOURS:5,075 COSTS(000):$0
Voluntary Partner Surveys to Implement Executive Order 12862 in
the Health Resources and Services Administration
FORMS: NONE
OMB NO: 0915-0230 EXPIRATION DATE: 08/31/2008
RESPS:2,900 HOURS:1,450 COSTS(000):$0
NHSC Recruitment and Retention Assistance Application
FORMS: NONE
OMB NO: 0915-0232 EXPIRATION DATE: 10/31/2008
RESPS:900 HOURS:32,400 COSTS(000):$83
National Health Service Corps - Uniform Data System
FORMS: NONE
OMB NO: 0915-0233 EXPIRATION DATE: 09/30/2008
RESPS:150 HOURS:825 COSTS(000):$0
Disadvantaged Assistance Tracking and Outcome Report (DATOR) for
Health Careers Opportunity Program and Centers of Excellence
Program
FORMS: NONE
OMB NO: 0915-0239 EXPIRATION DATE: 08/31/2007
RESPS:946,515 HOURS:116,146 COSTS(000):$4,074
Health Integrity and Protection Data Bank for Final Adverse
Information on Health Care Providers, Suppliers and Practitioners
FORMS: NONE
OMB NO: 0915-0247 EXPIRATION DATE: 01/31/2007
RESPS:60 HOURS:3,840 COSTS(000):$0
Children's Hospital Graduate Medical Eduction Program
FORMS: NONE
OMB NO: 0915-0250 EXPIRATION DATE: 06/30/2007
RESPS:1,350 HOURS:276 COSTS(000):$0
The National Health Service Corps Scholarship Program In-School
Worksheets
FORMS: NONE
OMB NO: 0915-0253 EXPIRATION DATE: 12/31/2007
RESPS:3,367 HOURS:107,636 COSTS(000):$0
Ryan White Comprehensive Aids Resources Emergency Act of 1990,
CARE Act Data Report (CADR) System
FORMS: NONE
OMB NO: 0915-0262 EXPIRATION DATE: 12/31/2006
RESPS:212 HOURS:3,816 COSTS(000):$0
Office of State and National Partnership's Web-based Semi Annual
Report
FORMS: NONE
OMB NO: 0915-0268 EXPIRATION DATE: 02/28/2009
RESPS:86 HOURS:688 COSTS(000):$0
Implementation of the Primary Care Surveillance System (PSCC)
Core Data Collection Effort for the Sentinal Centers Network
(SCN)
FORMS: NONE
OMB NO: 0915-0275 EXPIRATION DATE: 12/31/2007
RESPS:16,800 HOURS:25,200 COSTS(000):$0
Ryan White Comprehensive Aids Resources Emergency Act of 1990,
Title III and IV Client-Level Data Project (CDP) Reporting System
FORMS: NONE
OMB NO: 0915-0278 EXPIRATION DATE: 10/31/2006
RESPS:622 HOURS:41 COSTS(000):$0
NHSC Travel Request Worksheet
FORMS: NONE
OMB NO: 0915-0281 EXPIRATION DATE: 12/31/2006
RESPS:13,536 HOURS:32,502 COSTS(000):$0
AIDS Education and Training Centers
FORMS: NONE
OMB NO: 0915-0282 EXPIRATION DATE: 08/31/2007
RESPS:2,500 HOURS:7,500 COSTS(000):$0
Smallpox Vaccine Injury Compensation Program
FORMS: NONE
OMB NO: 0915-0285 EXPIRATION DATE: 06/30/2007
RESPS:1,425 HOURS:59,375 COSTS(000):$0
The Presidential Initiative Applications for Funding
Opportunities
FORMS: NONE
OMB NO: 0915-0286 EXPIRATION DATE: 06/30/2007
RESPS:4 HOURS:18 COSTS(000):$0
Organ Procurement and Transplantation Network (42 CFR Part
121.3(b)(4) and 121.9(d))
FORMS: NONE
OMB NO: 0915-0289 EXPIRATION DATE: 09/30/2007
RESPS:314 HOURS:14,130 COSTS(000):$0
Health Care Infrastructure Application Forms for Funding
Opportunities
FORMS: NONE
OMB NO: 0915-0292 EXPIRATION DATE: 09/30/2007
RESPS:15 HOURS:150 COSTS(000):$0
Black Lung Clinics Program Database
FORMS: NONE
OMB NO: 0915-0293 EXPIRATION DATE: 08/31/2008
RESPS:150 HOURS:2,400 COSTS(000):$0
Free Clinics FTCA Program Application
FORMS: NONE
OMB NO: 0915-0294 EXPIRATION DATE: 01/31/2008
RESPS:228 HOURS:428 COSTS(000):$0
HRSA AIDS Drug Assistance Quarterly Report
FORMS: NONE
OMB NO: 0915-0295 EXPIRATION DATE: 02/29/2008
RESPS:4,900 HOURS:2,750 COSTS(000):$0
Grant Reviewer Recruitment Form
FORMS: NONE
OMB NO: 0915-0297 EXPIRATION DATE: 09/30/2006
RESPS:126 HOURS:108 COSTS(000):$0
Survey of Universal Newborn Hearing Screening and Intervention
Programs
FORMS: NONE
OMB NO: 0915-0298 EXPIRATION DATE: 03/31/2009
RESPS:631 HOURS:3,786 COSTS(000):$0
Maternal and Child Health Bureau Performance Measures for
Discretionary Grants
FORMS: NONE
OMB NO: 0915-0300 EXPIRATION DATE: 06/30/2007
RESPS:633 HOURS:316 COSTS(000):$0
Healthy Start Participant Survey
FORMS: NONE
OMB NO: 0915-0301 EXPIRATION DATE: 07/31/2009
RESPS:5,000 HOURS:4,750 COSTS(000):$0
The Nursing Scholarship Program
FORMS: NONE
SUBAGENCY TOTALS
ACTIVE ANNUAL ANNUAL ANNUAL
REPORTS RESPONSES HOURS COSTS($000)
52 5,485,371 1,257,251 $31,709
Indian Health Service
OMB NO: 0917-0002 EXPIRATION DATE: 11/30/2006
RESPS:338,403 HOURS:16,920 COSTS(000):$0
IHS Contract Health Service Purchase-Delivery Order for Health
Service
FORMS: IHS843-1A
OMB NO: 0917-0006 EXPIRATION DATE: 09/30/2007
RESPS:17,330 HOURS:5,536 COSTS(000):$0
IHS Scholarship Program Application
FORMS: 856 856-2 856-3 856-4 856-5 856-6
OMB NO: 0917-0007 EXPIRATION DATE: 09/30/2007
RESPS:34 HOURS:514 COSTS(000):$0
IHS Urban Indian Health Program Common Reporting Requirements
FORMS: NONE
OMB NO: 0917-0009 EXPIRATION DATE: 08/31/2006
RESPS:3,709 HOURS:2,371 COSTS(000):$0
Indian Health Service Medical Staff Credentials and Privileges
Files
FORMS: NONE
OMB NO: 0917-0014 EXPIRATION DATE: 12/31/2008
RESPS:2,125 HOURS:1,382 COSTS(000):$0
Indian Health Service Loan Repayment Program
FORMS: NONE
OMB NO: 0917-0025 EXPIRATION DATE: 05/31/2007
RESPS:1 HOURS:384 COSTS(000):$0
Hoz'ho'nii: An Intervention to Increase Breat and Cervical
Cancer Screening Among Navajo Women
FORMS: NONE
OMB NO: 0917-0026 EXPIRATION DATE: 12/31/2008
RESPS:50 HOURS:3,720 COSTS(000):$0
Final Rule to Implement Title V of the Tribal Self-Governance
Amendments of 2000
FORMS: NONE
OMB NO: 0917-0028 EXPIRATION DATE: 02/28/2009
RESPS:2,000 HOURS:500 COSTS(000):$0
IHS Background Investigations of Individuals in Positions
Involving Regular Contact with or Control Over Indian Children
FORMS: 306
OMB NO: 0917-0030 EXPIRATION DATE: 08/31/2006
RESPS:542,500 HOURS:174,375 COSTS(000):$0
IHS Forms To Implement The Privacy Rule (45 CFR Parts 160 and
164)
FORMS: NONE
OMB NO: 0917-0031 EXPIRATION DATE: 07/31/2007
RESPS:108 HOURS:18 COSTS(000):$0
Chief Executive Officer Retention Survey
FORMS: NONE
SUBAGENCY TOTALS
ACTIVE ANNUAL ANNUAL ANNUAL
REPORTS RESPONSES HOURS COSTS($000)
10 906,260 205,720 $0
Centers for Disease Control and Prevention
OMB NO: 0920-0004 EXPIRATION DATE: 10/31/2006
RESPS:1,277 HOURS:12,732 COSTS(000):$0
National Disease Surveillance Program - II. Disease Summaries
FORMS: CDC-52.12 52.13 52.19 52.20 52.28 55.41 55.9 55.20 55.31
55.31A/55.83A-C
OMB NO: 0920-0006 EXPIRATION DATE: 02/28/2009
RESPS:600 HOURS:167 COSTS(000):$16
Application for Waiver of Inadmissibility Under Immigration and
Nationality Act
FORMS: CDC-4.422-1 CDC-4.422-1A CDC-4.422-1B
OMB NO: 0920-0007 EXPIRATION DATE: 07/31/2007
RESPS:12,329 HOURS:5,455 COSTS(000):$0
Weekly and Annual Morbidity and Mortality Reports
FORMS: CDC43.5A
OMB NO: 0920-0008 EXPIRATION DATE: 09/30/2006
RESPS:15,000 HOURS:3,750 COSTS(000):$0
Emergency Epidemic Investigations
FORMS: NONE
OMB NO: 0920-0009 EXPIRATION DATE: 11/30/2006
RESPS:51,564 HOURS:14,508 COSTS(000):$0
National Disease Surveillance Program - 1. Case Reports
FORMS: CDC-53.1 CDC-52.15 CDC-56.31A CDC-56.31B CDC-55.54 CDC-52-56
CDC-52.18 CDC-52.60 CDC-54.1 CDC-56.37
OMB NO: 0920-0010 EXPIRATION DATE: 05/31/2009
RESPS:400 HOURS:600 COSTS(000):$0
National Birth Defects Prevention Study (formerly titled: Metro
Atlanta Birth Defects & Factor Surveillance Program)
FORMS: NONE
OMB NO: 0920-0012 EXPIRATION DATE: 02/29/2008
RESPS:83,890 HOURS:66,775 COSTS(000):$47,520
National Nosocomial Infections Surveillance System (NNIS)
FORMS: NONE
OMB NO: 0920-0017 EXPIRATION DATE: 12/31/2006
RESPS:45,525 HOURS:3,582 COSTS(000):$0
Application for Training
FORMS: CDC-FORM-32.1 CDC-FORM-36.5
OMB NO: 0920-0020 EXPIRATION DATE: 09/30/2007
RESPS:8,025 HOURS:1,246 COSTS(000):$0
National Coal Workers' X-ray Surveillance Program (CWXSP) -
Federal Mine Safety and Health Act 1977 (42CFR37)
FORMS: NIOSH(M)-2.8 NIOSH(M)-2.9 NIOSH(M)-2.10 NIOSH(M)-2.11
NIOSH(M)-2.12
OMB NO: 0920-0021 EXPIRATION DATE: 11/30/2006
RESPS:50 HOURS:21 COSTS(000):$0
National Coal Workers' Autopsy Study (42 cfr 37.204)
FORMS: CDC/NIOSH-2.6
OMB NO: 0920-0026 EXPIRATION DATE: 11/30/2008
RESPS:15,120 HOURS:7,560 COSTS(000):$0
National Tuberculosis Surveillance
FORMS: CDC-72.9A CDC-72.9B CDC-72.9C
OMB NO: 0920-0106 EXPIRATION DATE: 10/31/2008
RESPS:122 HOURS:4,270 COSTS(000):$0
Preventive Health and Health Services Block Grant
FORMS: NONE
OMB NO: 0920-0109 EXPIRATION DATE: 11/30/2007
RESPS:430 HOURS:98,470 COSTS(000):$0
Information Collection Provisions in 42 CFR Part 84 - Tests and
Requirements for Certification and Approval of Respiratory
Protective Devices
FORMS: NONE
OMB NO: 0920-0128 EXPIRATION DATE: 09/30/2006
RESPS:500 HOURS:130 COSTS(000):$0
Congenital Syphilis Case Investigation and Report Form
FORMS: CDC-73.126
OMB NO: 0920-0134 EXPIRATION DATE: 12/31/2008
RESPS:2,711,601 HOURS:225,759 COSTS(000):$0
Foreign Quarantine Regulations
FORMS: NONE
OMB NO: 0920-0138 EXPIRATION DATE: 02/29/2008
RESPS:67 HOURS:52 COSTS(000):$0
Pulmonary Function Testing Course Approval Program
FORMS: NONE
OMB NO: 0920-0199 EXPIRATION DATE: 08/31/2006
RESPS:4,452 HOURS:1,206 COSTS(000):$0
Importation and Transportation of Etiologic Agents (42 CFR 71.54
and Part 72)
FORMS: 0.753
OMB NO: 0920-0210 EXPIRATION DATE: 08/31/2007
RESPS:143 HOURS:930 COSTS(000):$0
List of Ingredients Added in the Manufacture of Cigarette
Products
FORMS: NONE
OMB NO: 0920-0212 EXPIRATION DATE: 08/31/2008
RESPS:47,525 HOURS:2,131 COSTS(000):$0
National Hospital Discharge Survey
FORMS: NONE
OMB NO: 0920-0213 EXPIRATION DATE: 02/28/2009
RESPS:1,150 HOURS:208 COSTS(000):$0
National Vital Statistics Report Forms
FORMS: CDC-64.147 CDC-64.146
OMB NO: 0920-0214 EXPIRATION DATE: 12/31/2007
RESPS:43,417 HOURS:36,821 COSTS(000):$0
National Health Interview Survey: Basic Module with 2005 Topical
Modules
FORMS: NONE
OMB NO: 0920-0215 EXPIRATION DATE: 11/30/2007
RESPS:780 HOURS:227 COSTS(000):$0
Application form and related forms for the operation of the
National Death Index
FORMS: CDC/NCHS-6205-1 CDC-64.24 CDC-64.25 PHS-6205-3 CDC/NCHS-6205-6
OMB NO: 0920-0217 EXPIRATION DATE: 07/31/2007
RESPS:157 HOURS:44 COSTS(000):$0
NCHS Application for Vital Statistics Training Form
FORMS: CDC-64.52
OMB NO: 0920-0222 EXPIRATION DATE: 01/31/2007
RESPS:460 HOURS:600 COSTS(000):$0
NCHS Questionnaire Design Research Laboratory
FORMS: NONE
OMB NO: 0920-0234 EXPIRATION DATE: 05/31/2007
RESPS:85,360 HOURS:7,460 COSTS(000):$0
NCHS National Ambulatory Medical Care Survey, 2005-2006
FORMS: CDC-64.148 CDC-64.149
OMB NO: 0920-0237 EXPIRATION DATE: 03/31/2007
RESPS:22,913 HOURS:63,092 COSTS(000):$0
NCHS National Health and Nutrition Examination Survey (NHANES)
2005-2006
FORMS: NONE
OMB NO: 0920-0255 EXPIRATION DATE: 08/31/2006
RESPS:19,133 HOURS:3,858 COSTS(000):$0
Resources and Services Database for the CDC National Prevention
Information Network
FORMS: NONE
OMB NO: 0920-0260 EXPIRATION DATE: 11/30/2007
RESPS:11,840 HOURS:3,991 COSTS(000):$0
Health Hazard Evaluations/Technical Assistance and Emerging
Problems
FORMS: NONE
OMB NO: 0920-0261 EXPIRATION DATE: 04/30/2007
RESPS:77 HOURS:10,631 COSTS(000):$0
NIOSH Training Grants Applications (42 CFR 86)
FORMS: CDC-2.145A CDC-2.145B
OMB NO: 0920-0263 EXPIRATION DATE: 05/31/2008
RESPS:100 HOURS:20 COSTS(000):$0
Requirements for a Special Permit to Import Cynomolgus, African
Green, or Rhesus Monkeys into the United States
FORMS: CDC-75.10A
OMB NO: 0920-0274 EXPIRATION DATE: 10/31/2007
RESPS:4,245 HOURS:1,057 COSTS(000):$0
CDC Model Performance Evaluation Program (MPEP) for Retroviral
and AIDS-Related Testing
FORMS: NONE
OMB NO: 0920-0278 EXPIRATION DATE: 05/31/2007
RESPS:94,970 HOURS:10,030 COSTS(000):$0
NCHS National Hospital Ambulatory Medical Care Survey, 2005-2006
FORMS: 101(CDC-64.151) 101U(CDC-64.150 CDC-64.136 CDC-64.135
OMB NO: 0920-0282 EXPIRATION DATE: 04/30/2007
RESPS:168 HOURS:336 COSTS(000):$0
The Childhood Lead Poisoning Prevention Program Quarterly Report
FORMS: NONE
OMB NO: 0920-0295 EXPIRATION DATE: 09/30/2006
RESPS:48,100 HOURS:1,342 COSTS(000):$0
National AIDS and STD Hotline Survey of Callers
FORMS: NONE
OMB NO: 0920-0298 EXPIRATION DATE: 07/31/2009
RESPS:12,320 HOURS:6,088 COSTS(000):$0
National Home and Hospice Care Survey
FORMS: NONE
OMB NO: 0920-0307 EXPIRATION DATE: 01/31/2008
RESPS:1,644 HOURS:8,142 COSTS(000):$0
Gonococcal Isolate Surveillance Project
FORMS: CDC-73.60A 73.60B 73.60C
OMB NO: 0920-0314 EXPIRATION DATE: 04/30/2009
RESPS:14,970 HOURS:6,457 COSTS(000):$0
National Survey of Family Growth, Cycle 7
FORMS: NONE
OMB NO: 0920-0334 EXPIRATION DATE: 11/30/2008
RESPS:70,272 HOURS:11,231 COSTS(000):$0
National Survey of Ambulatory Surgery
FORMS: NONE
OMB NO: 0920-0337 EXPIRATION DATE: 05/31/2008
RESPS:336 HOURS:672 COSTS(000):$0
National Blood Lead Surveillance System
FORMS: NONE
OMB NO: 0920-0338 EXPIRATION DATE: 08/31/2007
RESPS:11 HOURS:18,838 COSTS(000):$0
List of Ingredients Added in the Manufacture of Smokeless
Tobacco Products
FORMS: NONE
OMB NO: 0920-0353 EXPIRATION DATE: 05/31/2007
RESPS:29,250 HOURS:13,375 COSTS(000):$0
National Nursing Home Survey
FORMS: NONE
OMB NO: 0920-0406 EXPIRATION DATE: 11/30/2007
RESPS:620,325 HOURS:55,190 COSTS(000):$0
State and Local Area Integrated Telephone Survey (SLAITS)
FORMS: NONE
OMB NO: 0920-0417 EXPIRATION DATE: 02/29/2008
RESPS:1,349 HOURS:17,907 COSTS(000):$15
National Surveillance System for Health Care Workers
FORMS: NONE
OMB NO: 0920-0428 EXPIRATION DATE: 08/31/2006
RESPS:21,379 HOURS:49,049 COSTS(000):$0
PHS Supplements to Application for Federal Assistance (SF 424)
FORMS: SF-424 PHS-5161-1 CDC.124(E) CDC.0113 OPHS-1
OMB NO: 0920-0442 EXPIRATION DATE: 08/31/2006
RESPS:223 HOURS:6,300 COSTS(000):$0
Surveillance for Bloodstream and Vascular Access Infections in
Outpatient Hemodialysis Centers
FORMS: NONE
OMB NO: 0920-0445 EXPIRATION DATE: 11/30/2008
RESPS:19.086 HOURS:22,812 COSTS(000):$0
School Health Policies and Programs Study 2006 (SHPPS 2006)
FORMS: NONE
OMB NO: 0920-0457 EXPIRATION DATE: 08/31/2006
RESPS:68 HOURS:340 COSTS(000):$0
Aggregate Reports for Tuberculosis Program Evaluation
FORMS: NONE
OMB NO: 0920-0463 EXPIRATION DATE: 04/30/2009
RESPS:100 HOURS:50 COSTS(000):$0
Longitudinal Surveillance for Beryllium Disease Prevention
FORMS: NONE
OMB NO: 0920-0469 EXPIRATION DATE: 11/30/2006
RESPS:63 HOURS:126 COSTS(000):$0
National Program of Cancer Registries Cancer Surveillance System
FORMS: NONE
OMB NO: 0920-0472 EXPIRATION DATE: 09/30/2006
RESPS:16,749 HOURS:2,689 COSTS(000):$0
Assessment of Exposure to Aresenic Through Household Water
FORMS: NONE
OMB NO: 0920-0479 EXPIRATION DATE: 08/31/2006
RESPS:59 HOURS:236 COSTS(000):$1
Automated Management Information System (MIS) for Diabetes
Control Programs
FORMS: NONE
OMB NO: 0920-0487 EXPIRATION DATE: 09/30/2006
RESPS:745 HOURS:173 COSTS(000):$0
Risk Factors for Microbial Contamination of Produce: A Field
Study of Domestic and Imported Produce in Packing Sheds
FORMS: NONE
OMB NO: 0920-0488 EXPIRATION DATE: 12/31/2006
RESPS:16,500 HOURS:3,600 COSTS(000):$0
Restrictions on Interstate Travel of Persons
FORMS: NONE
OMB NO: 0920-0489 EXPIRATION DATE: 04/30/2008
RESPS:3,960 HOURS:3,960 COSTS(000):$0
US-MX Border Diabetes Prevention and Control Project - Phase 2
Community Intervention Pilot Study
FORMS: NONE
OMB NO: 0920-0493 EXPIRATION DATE: 11/30/2007
RESPS:8,230 HOURS:6,115 COSTS(000):$0
2005 and 2007 Youth Risk Behavior Surveys
FORMS: NONE
OMB NO: 0920-0494 EXPIRATION DATE: 12/31/2008
RESPS:605 HOURS:128 COSTS(000):$0
Exposure to Aerosolized Brevetoxins During Red Tide Events
FORMS: NONE
OMB NO: 0920-0499 EXPIRATION DATE: 08/31/2007
RESPS:80 HOURS:800 COSTS(000):$0
Jail STD Prevalence Monitoring System
FORMS: NONE
OMB NO: 0920-0502 EXPIRATION DATE: 06/30/2007
RESPS:29,647 HOURS:8,138 COSTS(000):$0
REACH 2010 Evaluation
FORMS: NONE
OMB NO: 0920-0527 EXPIRATION DATE: 02/28/2007
RESPS:638 HOURS:231 COSTS(000):$0
Human Exposure to Cynobacterial (Blue-green Algal) Toxins in
Drinking Water: Risk of Exposure to Microcystins from Public
Water Systems
FORMS: NONE
OMB NO: 0920-0530 EXPIRATION DATE: 01/31/2009
RESPS:12,600 HOURS:4,900 COSTS(000):$0
EEOICPA Dose Reconstruction Interviews and Form
FORMS: OCAS-1
OMB NO: 0920-0555 EXPIRATION DATE: 12/31/2008
RESPS:175 HOURS:4,200 COSTS(000):$0
National Public Health Performance Standards Program Local
Public Health Performance Assessment
FORMS: NONE
OMB NO: 0920-0556 EXPIRATION DATE: 08/31/2006
RESPS:400 HOURS:63,400 COSTS(000):$0
Assisted Reproductive Technology (ART) Program Reporting System
FORMS: NONE
OMB NO: 0920-0557 EXPIRATION DATE: 12/31/2008
RESPS:7 HOURS:105 COSTS(000):$0
National Public Health Performance Standards Program State
Public Health Performance Assessment
FORMS: NONE
OMB NO: 0920-0571 EXPIRATION DATE: 11/30/2006
RESPS:273 HOURS:2,343 COSTS(000):$0
Minimum Data Elements/System for Technical Assistance Reporting
for the National Breast and Cervical Cancer Early Detection
Program
FORMS: NONE
OMB NO: 0920-0572 EXPIRATION DATE: 06/30/2008
RESPS:6,400 HOURS:2,500 COSTS(000):$0
CDC and ATSDR Health Massage Testing System
FORMS: NONE
OMB NO: 0920-0573 EXPIRATION DATE: 11/30/2006
RESPS:79,981 HOURS:13,191 COSTS(000):$0
Adult and Pediatric Confidential HIV/AIDS Case Report
FORMS: CDC-50.42A CDC-50.42B
OMB NO: 0920-0576 EXPIRATION DATE: 03/31/2009
RESPS:5,324 HOURS:7,785 COSTS(000):$0
Possession, Use, and Transfer of Select Agents and Toxins (42
CFR 73)
FORMS: 0.1316 0.1317 0.1318 0.1319 EA-101
OMB NO: 0920-0580 EXPIRATION DATE: 12/31/2006
RESPS:1,067 HOURS:6,402 COSTS(000):$0
National Public Health Performance Standards Program Local
Public Health Governance Performance Assessment Tool
FORMS: NONE
OMB NO: 0920-0582 EXPIRATION DATE: 05/31/2007
RESPS:33,127 HOURS:2,362 COSTS(000):$0
YMC Tracking Study
FORMS: NONE
OMB NO: 0920-0587 EXPIRATION DATE: 11/30/2006
RESPS:29,490 HOURS:4,887 COSTS(000):$0
Outcome Follow-up Survey of CDC's Youth Media Campaign
FORMS: NONE
OMB NO: 0920-0591 EXPIRATION DATE: 09/30/2007
RESPS:900 HOURS:450 COSTS(000):$0
Select Agent Distribution Activity; Request for Select Agent
FORMS: NONE
OMB NO: 0920-0595 EXPIRATION DATE: 12/31/2006
RESPS:900 HOURS:175 COSTS(000):$0
HIV Rapid Testing Performance Evaluation Sample and Laboratory
Practices Questionnaire Surveys
FORMS: NONE
OMB NO: 0920-0596 EXPIRATION DATE: 09/30/2007
RESPS:5,700 HOURS:1,583 COSTS(000):$0
Severe Acute Respiratory Syndrome (SARS) Investigation
FORMS: NONE
OMB NO: 0920-0599 EXPIRATION DATE: 09/30/2007
RESPS:1,070 HOURS:555 COSTS(000):$0
A Community-Based Intervention Model to Promote Neighborhood
Participation in the Reduction of Aedes aegypti indices in
Puerto Rico
FORMS: CDC-50.133
OMB NO: 0920-0600 EXPIRATION DATE: 09/30/2006
RESPS:330 HOURS:165 COSTS(000):$0
Centers for Disease Control and Prevention Performance
Evaluation Program for Mycobacterium
Tuberculosis/Non-tuberculosis Mycobacteria Drug Susceptibility
Testing Program
FORMS: NONE
OMB NO: 0920-0601 EXPIRATION DATE: 08/31/2006
RESPS:102 HOURS:612 COSTS(000):$0
National Tobacco Control Program Chronicle Progress Reporting
System
FORMS: NONE
OMB NO: 0920-0602 EXPIRATION DATE: 10/31/2006
RESPS:90,048 HOURS:28,860 COSTS(000):$0
Work and Health Study: Risk Factors for Heart Disease and
Depression in the Workplace
FORMS: NONE
OMB NO: 0920-0603 EXPIRATION DATE: 09/30/2006
RESPS:84 HOURS:84 COSTS(000):$0
Racial and Ethnic Approaches to Community Health 2010
Information Network (REACH IN)
FORMS: NONE
OMB NO: 0920-0604 EXPIRATION DATE: 11/30/2006
RESPS:70 HOURS:70 COSTS(000):$0
School-Associated Violent Deaths Surveillance System
FORMS: NONE
OMB NO: 0920-0607 EXPIRATION DATE: 11/30/2006
RESPS:20,000 HOURS:25,000 COSTS(000):$0
The National Violent Death Reporting System (NVDRS)
FORMS: NONE
OMB NO: 0920-0610 EXPIRATION DATE: 12/31/2006
RESPS:650 HOURS:325 COSTS(000):$0
Evaluation of the Process Required to Effectively Expand the
National Laboratory System (NLS) to All States
FORMS: NONE
OMB NO: 0920-0612 EXPIRATION DATE: 11/30/2006
RESPS:150 HOURS:2,160 COSTS(000):$0
WISEWOMAN Reporting System
FORMS: NONE
OMB NO: 0920-0614 EXPIRATION DATE: 11/30/2006
RESPS:5 HOURS:120 COSTS(000):$0
International Performance Standards Project
FORMS: NONE
OMB NO: 0920-0621 EXPIRATION DATE: 12/31/2008
RESPS:25,037 HOURS:18,644 COSTS(000):$0
National Youth Tobacco Survey (NYTS)
FORMS: NONE
OMB NO: 0920-0622 EXPIRATION DATE: 01/31/2007
RESPS:532 HOURS:400 COSTS(000):$0
The Domestic Violence Prevention Enhancement and Leadership
through Alliances (DELTA) Program
FORMS: NONE
OMB NO: 0920-0624 EXPIRATION DATE: 10/31/2008
RESPS:667 HOURS:167 COSTS(000):$0
An Evaluation of the Use and Effectiveness of Internet SAMMEC
FORMS: NONE
OMB NO: 0920-0628 EXPIRATION DATE: 03/31/2007
RESPS:4,015 HOURS:6,030 COSTS(000):$0
Housing and Health Study
FORMS: NONE
OMB NO: 0920-0630 EXPIRATION DATE: 04/30/2007
RESPS:2,550 HOURS:1,892 COSTS(000):$0
Work Organization Predictors of Depression in Women
FORMS: NONE
OMB NO: 0920-0632 EXPIRATION DATE: 02/28/2007
RESPS:2,000 HOURS:400 COSTS(000):$0
Clinicians' Management Approach to Children with Pharyngitis
FORMS: NONE
OMB NO: 0920-0636 EXPIRATION DATE: 12/31/2007
RESPS:1,000 HOURS:167 COSTS(000):$0
State-Based Evaluation of the Alert Notification Component of
CDC's Secure Communications Network (EPI-X)
FORMS: NONE
OMB NO: 0920-0639 EXPIRATION DATE: 05/31/2007
RESPS:90 HOURS:54 COSTS(000):$0
EEOICPA Special Exposure Cohort Petition Forms (42 CFR Part 8)
FORMS: NONE
OMB NO: 0920-0641 EXPIRATION DATE: 09/30/2006
RESPS:217 HOURS:36 COSTS(000):$0
Descriptive Epidemiology of Missed or Delayed Diagnosis for
Conditions Detected by Newborn Screening
FORMS: NONE
OMB NO: 0920-0643 EXPIRATION DATE: 06/30/2007
RESPS:221,600 HOURS:17,026 COSTS(000):$0
Assessment Information About the National Center for Injury
Prevention and Control (NCIPC) Publications
FORMS: NONE
OMB NO: 0920-0646 EXPIRATION DATE: 08/31/2007
RESPS:31,325 HOURS:2,365 COSTS(000):$0
Cross-sectional Survey for the Evaluation of the CDC Youth Media
Campaign
FORMS: NONE
OMB NO: 0920-0648 EXPIRATION DATE: 07/31/2007
RESPS:100 HOURS:58 COSTS(000):$0
NCHS Technology and Aging Pilot Survey
FORMS: NONE
OMB NO: 0920-0649 EXPIRATION DATE: 09/30/2007
RESPS:29,125 HOURS:4,855 COSTS(000):$0
Assessment of Educational Materials and Information Distribution
Systems
FORMS: NONE
OMB NO: 0920-0650 EXPIRATION DATE: 11/30/2007
RESPS:132 HOURS:279 COSTS(000):$0
Prevention Research Centers Information System
FORMS: NONE
OMB NO: 0920-0651 EXPIRATION DATE: 07/31/2008
RESPS:240 HOURS:210 COSTS(000):$0
Evaluation of Educational Materials Promoting Informed Decision
Making About Prostate Cancer Screening - PHASE II: RCT
FORMS: 35038-25
OMB NO: 0920-0655 EXPIRATION DATE: 09/30/2006
RESPS:656 HOURS:100 COSTS(000):$0
Accommodation of Noise-Exposed, Hearing-Impaired Workers
FORMS: NONE
OMB NO: 0920-0658 EXPIRATION DATE: 11/30/2007
RESPS:3,060 HOURS:1,462 COSTS(000):$0
CDC HIV Prevention Capacity-Building Assistance (CBA)
Information Collection, Reporting, and Monitoring Forms
FORMS: NONE
OMB NO: 0920-0660 EXPIRATION DATE: 02/29/2008
RESPS:504 HOURS:109 COSTS(000):$0
Surveillance Survey for the Guide to Community Preventive
Services
FORMS: NONE
OMB NO: 0920-0662 EXPIRATION DATE: 01/31/2008
RESPS:56 HOURS:36 COSTS(000):$0
Learning from Principal Investigators of Research Projects
Funded through the Extramural Prevention Research Program: How
Can CDC Best Support Participatory Research and the....
FORMS: NONE
OMB NO: 0920-0666 EXPIRATION DATE: 02/29/2008
RESPS:174,395 HOURS:65,817 COSTS(000):$39,600
The National Healthcare Safety Network
FORMS: 57.75A-Z 57.75Z(1-3) 57.75AA-DD
OMB NO: 0920-0667 EXPIRATION DATE: 09/30/2006
RESPS:1,637 HOURS:250 COSTS(000):$0
Active Surveillance for Ciguatera Fish Poisoning in Culebra,
Puerto Rico
FORMS: NONE
OMB NO: 0920-0668 EXPIRATION DATE: 02/28/2007
RESPS:1,138 HOURS:570 COSTS(000):$0
Minority HIV/AIDS Research Initiative: "Access to HIV Testing
and Treatment in the Rural South"
FORMS: NONE
OMB NO: 0920-0669 EXPIRATION DATE: 01/31/2008
RESPS:40 HOURS:672 COSTS(000):$0
Evaluation of "State Nutrition and Physical Activity Programs to
Prevent Obesity and Other Chronic Diseases"
FORMS: NONE
OMB NO: 0920-0670 EXPIRATION DATE: 09/30/2006
RESPS:1,800 HOURS:300 COSTS(000):$0
Evaluation of Efficacy of Household Water Filtration/Treatment
Devices in Households with Private Wells
FORMS: NONE
OMB NO: 0920-0671 EXPIRATION DATE: 01/31/2008
RESPS:909 HOURS:609 COSTS(000):$0
American Indian and Alaska Native Adult Tobacco Surveys
FORMS: NONE
OMB NO: 0920-0672 EXPIRATION DATE: 02/29/2008
RESPS:96 HOURS:718 COSTS(000):$0
Indicators of the Performance of Local and State Education
Agencies in HIV Prevention and Coordinated School Health Program
Activities for Adolescent and School Health Programs
FORMS: NONE
OMB NO: 0920-0673 EXPIRATION DATE: 02/28/2007
RESPS:14,750 HOURS:1,750 COSTS(000):$0
ACHES (Arthritis Conditions Health Effects Survey)
FORMS: NONE
OMB NO: 0920-0674 EXPIRATION DATE: 01/31/2008
RESPS:4,045 HOURS:301 COSTS(000):$0
Evaluation of a Concussion Tool Kit - Heads Up: Concussion in
High School Sports
FORMS: NONE
OMB NO: 0920-0675 EXPIRATION DATE: 11/30/2006
RESPS:311 HOURS:156 COSTS(000):$0
Evaluation of the James A. Ferguson Emerging Infectious Diseases
Fellowship Program
FORMS: NONE
OMB NO: 0920-0677 EXPIRATION DATE: 02/29/2008
RESPS:140 HOURS:47 COSTS(000):$0
Sexually Transmitted Diseases Laboratory Test Method Survey
FORMS: NONE
OMB NO: 0920-0678 EXPIRATION DATE: 11/30/2006
RESPS:630 HOURS:158 COSTS(000):$0
Increasing Cervical Cancer Screening in Never or Rarely Screened
Black Women: Phase I
FORMS: NONE
OMB NO: 0920-0679 EXPIRATION DATE: 05/31/2008
RESPS:132 HOURS:396 COSTS(000):$0
Cardiovascular Health Branch Management Information System
FORMS: NONE
OMB NO: 0920-0680 EXPIRATION DATE: 10/31/2008
RESPS:108 HOURS:18 COSTS(000):$0
Severe Acute Respitory Syndrome (SARS) Model Performance
Evaluation Program (MPEP)
FORMS: NONE
OMB NO: 0920-0681 EXPIRATION DATE: 02/28/2007
RESPS:115 HOURS:145 COSTS(000):$0
Comprehensive Cancer Control: Implementation Case Studies
FORMS: NONE
OMB NO: 0920-0682 EXPIRATION DATE: 12/31/2006
RESPS:344 HOURS:460 COSTS(000):$0
Assessment of Occupational Exposures to Electric and Magnetic
Fields (EMF)
FORMS: NONE
OMB NO: 0920-0684 EXPIRATION DATE: 08/31/2007
RESPS:20,920 HOURS:5,922 COSTS(000):$0
Evaluating Tools for Health Promotion and Disease Prevention
FORMS: NONE
OMB NO: 0920-0686 EXPIRATION DATE: 10/31/2006
RESPS:356 HOURS:178 COSTS(000):$0
Ecology of Bats in Households: A Survey for Assessing Knowledge,
Attitudes, and Health Risks
FORMS: NONE
OMB NO: 0920-0689 EXPIRATION DATE: 08/31/2008
RESPS:199 HOURS:56 COSTS(000):$0
Factors Impacting Effective Removal of Arsenic by Household
Water Purification Systems
FORMS: NONE
OMB NO: 0920-0691 EXPIRATION DATE: 08/31/2008
RESPS:102 HOURS:26 COSTS(000):$0
State Medicaid Tobacco Coverage Survey
FORMS: NONE
OMB NO: 0920-0692 EXPIRATION DATE: 08/31/2008
RESPS:4,000 HOURS:2,000 COSTS(000):$0
A Survey of the Knowledge, Attitudes, and Practice of Medical
and Allied Health Professionals Regarding Fetal Alcohol Exposure
FORMS: NONE
OMB NO: 0920-0693 EXPIRATION DATE: 10/31/2008
RESPS:625 HOURS:646 COSTS(000):$0
Validating Autism Surveillance Methodology in Metropolitan
Atlanta Developmental Disabilities Surveillance Program (MADDSP)
FORMS: NONE
OMB NO: 0920-0694 EXPIRATION DATE: 11/30/2008
RESPS:150 HOURS:54 COSTS(000):$0
Potential Reproductive and Neurological Effects of Exposure to
Acrylamide
FORMS: NONE
OMB NO: 0920-0696 EXPIRATION DATE: 11/30/2006
RESPS:2,152 HOURS:122,172 COSTS(000):$2
HIV Prevention Program Evaluation and Monitoring System for
Health Departments and Community-Based Organizations (PEMS)
FORMS: NONE
OMB NO: 0920-0697 EXPIRATION DATE: 10/31/2007
RESPS:678 HOURS:285 COSTS(000):$0
Fire Fighter Fatality Investigation and Prevention Program
(FFFIPP)
FORMS: NONE
OMB NO: 0920-0698 EXPIRATION DATE: 11/30/2007
RESPS:50 HOURS:25 COSTS(000):$0
How Miners Modify Their Behavior in Response To Personal Dust
Monitor Information
FORMS: NONE
OMB NO: 0920-0699 EXPIRATION DATE: 11/30/2008
RESPS:6,900 HOURS:18,970 COSTS(000):$0
Collection of Assessment Information about the Centers for
Disease Control and Prevention Publications
FORMS: NONE
OMB NO: 0920-0700 EXPIRATION DATE: 11/30/2008
RESPS:56,900 HOURS:18,970 COSTS(000):$0
Collection of Assessment Information About the Centers for
Disease Control and Prevention (CDC) Publications
FORMS: NONE
OMB NO: 0920-0701 EXPIRATION DATE: 05/31/2007
RESPS:2,400 HOURS:450 COSTS(000):$0
Determination of Antineoplastic Drug Exposure in Healthcare
Workers
FORMS: NONE
OMB NO: 0920-0702 EXPIRATION DATE: 01/31/2008
RESPS:124 HOURS:101 COSTS(000):$0
Comprehensive Cancer Control: Capacity Assessment
FORMS: NONE
OMB NO: 0920-0703 EXPIRATION DATE: 12/31/2008
RESPS:1,200 HOURS:400 COSTS(000):$0
Delayed Symptoms Associated with the Convalescent Period of a
Dengue Infection
FORMS: NONE
OMB NO: 0920-0704 EXPIRATION DATE: 12/31/2006
RESPS:9,016 HOURS:940 COSTS(000):$0
Assessment of State Early Hearing Detection and Intervention
Programs (EHDI); A program Operations Evaluation
FORMS: NONE
OMB NO: 0920-0705 EXPIRATION DATE: 12/31/2006
RESPS:5,440 HOURS:382 COSTS(000):$0
Evaluation of the Poison HELP Campaign to Enhance Public
Awareness of the National Poison Toll-Free Number, Poison Center
Access, and Poison Prevention
FORMS: NONE
OMB NO: 0920-0706 EXPIRATION DATE: 12/31/2008
RESPS:49 HOURS:74 COSTS(000):$0
National Program of Cancer Registries - Annual Program
Evaluation Instrument (NPCR-APEI)
FORMS: NONE
OMB NO: 0920-0707 EXPIRATION DATE: 01/31/2008
RESPS:1,000 HOURS:250 COSTS(000):$0
2005 Lead Disclosure Rule Public Awareness Survey
FORMS: NONE
OMB NO: 0920-0708 EXPIRATION DATE: 01/31/2007
RESPS:61 HOURS:105 COSTS(000):$0
Surveys of Past HIV Prevention Technology Transfer Efforts
FORMS: NONE
OMB NO: 0920-0709 EXPIRATION DATE: 01/31/2009
RESPS:554 HOURS:935 COSTS(000):$0
Spanish-Language Folic Acid Communication Research and Creative
Production
FORMS: NONE
OMB NO: 0920-0710 EXPIRATION DATE: 01/31/2007
RESPS:150 HOURS:45 COSTS(000):$0
Health Communication Planning, Implementation, and Evaluation
for People with Disabilities
FORMS: NONE
OMB NO: 0920-0714 EXPIRATION DATE: 03/31/2009
RESPS:12,288 HOURS:3,276 COSTS(000):$0
Evaluation and Assessment of the Effectiveness of Activities
Supporting Fire Prevention and Safety
FORMS: NONE
OMB NO: 0920-0715 EXPIRATION DATE: 04/30/2009
RESPS:20 HOURS:26 COSTS(000):$0
Integrating HIV and Other Prevention Services into Reproductive
Health and Other Community Setting Program Evaluation
FORMS: NONE
OMB NO: 0920-0716 EXPIRATION DATE: 04/30/2009
RESPS:872 HOURS:846 COSTS(000):$0
Process Evaluation of the Protocol for Assessing Community
Excellence in Environmental Health (PACE EH)
FORMS: NONE
OMB NO: 0920-0718 EXPIRATION DATE: 10/31/2007
RESPS:5,600 HOURS:3,968 COSTS(000):$0
Preventive Cardiac Health Care Knowledge, Beliefs, and Behaviors
in Female Carriers of Duchenne/Becker Muscular Dystrophy
FORMS: NONE
OMB NO: 0920-0720 EXPIRATION DATE: 06/30/2007
RESPS:2,000 HOURS:1,058 COSTS(000):$0
Economic Evaluation of Walking Behavior in Sedentary Adults Age
50 Years and Older
FORMS: NONE
OMB NO: 0920-0722 EXPIRATION DATE: 05/31/2007
RESPS:34,478 HOURS:7,253 COSTS(000):$0
HoME: Household Medkit Evaluation Study
FORMS: NONE
OMB NO: 0920-0723 EXPIRATION DATE: 05/31/2009
RESPS:200 HOURS:250 COSTS(000):$0
The Continuous Miner Tramming Study Interviews
FORMS: NONE
OMB NO: 0920-0724 EXPIRATION DATE: 08/31/2008
RESPS:15,065 HOURS:1,552 COSTS(000):$0
The National Intimate Partner and Sexual Violence Survey (NISVS)
FORMS: NONE
OMB NO: 0920-0725 EXPIRATION DATE: 06/30/2007
RESPS:1 HOURS:70 COSTS(000):$0
Understanding the Community Context of the Diabetes Education in
Tribal Schools Project
FORMS: NONE
OMB NO: 0920-0726 EXPIRATION DATE: 06/30/2008
RESPS:4,250 HOURS:1,833 COSTS(000):$0
2006 Hispanic/Latino Adult Tobacco Survey
FORMS: NONE
OMB NO: 0920-0729 EXPIRATION DATE: 06/30/2009
RESPS:2,680 HOURS:547 COSTS(000):$0
Customer Surveys Generic Clearance for the National Center for
Health Statistics
FORMS: NONE
SUBAGENCY TOTALS
ACTIVE ANNUAL ANNUAL ANNUAL
REPORTS RESPONSES HOURS COSTS($000)
151 5,183,861 1,324,264 $87,154
Agency for Toxic Substances and Disease Registry
OMB NO: 0923-0002 EXPIRATION DATE: 10/31/2006
RESPS:34 HOURS:17 COSTS(000):$0
Information Collection Procedures for Requesting Public Health
Assessments
FORMS: NONE
OMB NO: 0923-0006 EXPIRATION DATE: 08/31/2006
RESPS:1,667 HOURS:834 COSTS(000):$0
National Exposure Registry
FORMS: NONE
OMB NO: 0923-0007 EXPIRATION DATE: 11/30/2007
RESPS:150 HOURS:25 COSTS(000):$0
Community Assistance Panels Nomination Form
FORMS: NONE
OMB NO: 0923-0008 EXPIRATION DATE: 05/31/2008
RESPS:9,500 HOURS:6,050 COSTS(000):$0
Hazardous Substances Emergency Events Surveillance
FORMS: NONE
OMB NO: 0923-0028 EXPIRATION DATE: 02/28/2007
RESPS:4,981 HOURS:415 COSTS(000):$0
Evaluation of Customer Satisfaction with the Agency for Toxic
Substances and Disease Registry Internet Home Page and Links
FORMS: NONE
OMB NO: 0923-0035 EXPIRATION DATE: 07/31/2007
RESPS:500 HOURS:41 COSTS(000):$0
Online Evalution of a GIS Map Server Project with the Migrant
Clinicians Network
FORMS: NONE
OMB NO: 0923-0036 EXPIRATION DATE: 07/31/2007
RESPS:200 HOURS:150 COSTS(000):$0
Exposure to Volatile Organic Compounds in Drinking Water and
Specific Birth Defects and Childhood Cancers at United States
Marine Corps Base Camp Lejeune, North Carolina.
FORMS: NONE
OMB NO: 0923-0040 EXPIRATION DATE: 07/31/2009
RESPS:750 HOURS:375 COSTS(000):$0
NCEH/ATSDR Exposure Investigations (EI)
FORMS: NONE
SUBAGENCY TOTALS
ACTIVE ANNUAL ANNUAL ANNUAL
REPORTS RESPONSES HOURS COSTS($000)
8 17,782 7,907 $0
National Institutes of Health
OMB NO: 0925-0001 EXPIRATION DATE: 09/30/2007
RESPS:122,000 HOURS:1,032,439 COSTS(000):$500
Research and Research Training Grant Applications and Related
Forms
FORMS: PHS-398 2590 2271 3734 HHS-568
OMB NO: 0925-0002 EXPIRATION DATE: 10/31/2008
RESPS:51,822 HOURS:124,034 COSTS(000):$18
Individual Ruth L. Kirschstein National Research Service Award
Applications and Related Forms
FORMS: 416-5 416-7 416-9 6031 6031-1 PHS-416-1
OMB NO: 0925-0046 EXPIRATION DATE: 10/31/2006
RESPS:13,780 HOURS:2,010 COSTS(000):$0
Pretesting of NCI's Office of Communications Messages
FORMS: NONE
OMB NO: 0925-0208 EXPIRATION DATE: 11/30/2006
RESPS:405,900 HOURS:1,951 COSTS(000):$0
The National Cancer Institute Cancer Information Service
Demographic Customer Service Data Collection
FORMS: NONE
OMB NO: 0925-0216 EXPIRATION DATE: 12/31/2007
RESPS:12,202 HOURS:6,886 COSTS(000):$0
The Framingham Study
FORMS: NONE
OMB NO: 0925-0240 EXPIRATION DATE: 11/30/2007
RESPS:66,339 HOURS:3,378 COSTS(000):$0
Drug Accountability Record
FORMS: NIH-2564 NIH-2564-1
OMB NO: 0925-0281 EXPIRATION DATE: 02/28/2007
RESPS:13,640 HOURS:2,319 COSTS(000):$0
The Atherosclerosis Risk in Communities Study (ARIC)
FORMS: NONE
OMB NO: 0925-0299 EXPIRATION DATE: 08/31/2006
RESPS:21,545 HOURS:11,369 COSTS(000):$0
NIH Intramural Research Training Award Program Application
FORMS: NONE
OMB NO: 0925-0334 EXPIRATION DATE: 09/30/2007
RESPS:12,582 HOURS:868 COSTS(000):$0
The Cardiovascular, Heart Diseases Health Study
FORMS: NONE
OMB NO: 0925-0348 EXPIRATION DATE: 08/31/2006
RESPS:36 HOURS:360 COSTS(000):$0
Hazardous Waste Worker Training
FORMS: NONE
OMB NO: 0925-0361 EXPIRATION DATE: 06/30/2008
RESPS:12,468 HOURS:29,038 COSTS(000):$0
National Institutes of Health Loan Repayment Programs
FORMS: 2674-1-NO.7 2674-7 2674-2-NO.8 2674-8 2674-3-NO.9 2674-9
2674-4-NO.10 2674-10 2674-5-NO.11 2674-11
OMB NO: 0925-0368 EXPIRATION DATE: 04/30/2009
RESPS:95,000 HOURS:11,106 COSTS(000):$0
American Stop Smoking Intervention Study for Cancer Prevention
Final Eval.: "Tobacco Use Supplement to the 1998-99 Current
Population Survey"
FORMS: NONE
OMB NO: 0925-0378 EXPIRATION DATE: 08/31/2007
RESPS:200 HOURS:114 COSTS(000):$0
Application for the Pharmacology Research Associate Program
FORMS: NIH-2721-1 NIH-2721-2
OMB NO: 0925-0405 EXPIRATION DATE: 02/28/2007
RESPS:59,200 HOURS:29,500 COSTS(000):$0
Generic Clearance to Collect Medical Outcome and Risk Factor
Data from a Cohort of U.S. Radiologic Technologists
FORMS: NONE
OMB NO: 0925-0406 EXPIRATION DATE: 10/31/2008
RESPS:24,733 HOURS:44,270 COSTS(000):$0
Agricultural Health Study (A Prospective Cohort Study of Cancer
and Other Diseases Among Men and Women in Agriculture
FORMS: NONE
OMB NO: 0925-0407 EXPIRATION DATE: 10/31/2008
RESPS:1 HOURS:23,086 COSTS(000):$0
Prostate, Lung, Colorectal and Overian (PLCO) Cancer Screening
Trial
FORMS: NONE
OMB NO: 0925-0414 EXPIRATION DATE: 05/31/2009
RESPS:88,131 HOURS:18,319 COSTS(000):$0
Women's Health Initiative Observational Study
FORMS: NONE
OMB NO: 0925-0417 EXPIRATION DATE: 11/30/2008
RESPS:42,800 HOURS:232,000 COSTS(000):$4
Responsibility of Applicants for Promoting Objectivity in
Reserch for which Public Health Service Funding is Sought
FORMS: NONE
OMB NO: 0925-0424 EXPIRATION DATE: 08/31/2008
RESPS:16,481 HOURS:16,481 COSTS(000):$0
National Institutes of Health Construction Grants
FORMS: NONE
OMB NO: 0925-0438 EXPIRATION DATE: 12/31/2007
RESPS:1,580 HOURS:2,033 COSTS(000):$0
National Institutes of Health Undergraduate Scholarship Program
for Individuals from Disadvantaged Backgrounds
FORMS: NIH-2762-1 NIH-2762-2 NIH-2762-3 NIH-2762-4 NIH-2762-5
OMB NO: 0925-0454 EXPIRATION DATE: 01/31/2008
RESPS:862 HOURS:396 COSTS(000):$0
Case-Cohort Study of Cancer and Related Disorders Among
Benzene-Exposed Workers in China
FORMS: NONE
OMB NO: 0925-0458 EXPIRATION DATE: 06/30/2007
RESPS:2,965 HOURS:2,671 COSTS(000):$0
Satisfaction Surveys of Customers and Other Partners
FORMS: NONE
OMB NO: 0925-0465 EXPIRATION DATE: 10/31/2006
RESPS:2,441 HOURS:814 COSTS(000):$0
Re-contacting Participants in the Observing Protein and Energy
Nutrition (Re-OPEN) Study
FORMS: NONE
OMB NO: 0925-0474 EXPIRATION DATE: 09/30/2007
RESPS:2,100 HOURS:693 COSTS(000):$0
Generic Clearance for Satisfaction Surveys of Customers
FORMS: NONE
OMB NO: 0925-0475 EXPIRATION DATE: 11/30/2008
RESPS:400 HOURS:148 COSTS(000):$0
Training Tomorrow's Scientists: Linking Minorities and Mentors
Through the Web
FORMS: NONE
OMB NO: 0925-0476 EXPIRATION DATE: 07/31/2009
RESPS:19,758 HOURS:2,680 COSTS(000):$0
Request for Generic Clearance to Conduct Voluntary
Customer/Partner Surveys
FORMS: NONE
OMB NO: 0925-0479 EXPIRATION DATE: 09/30/2006
RESPS:51 HOURS:18 COSTS(000):$0
Request for Clearance to Conduct Voluntary Customer Satisfaction
Surveys
FORMS: NONE
OMB NO: 0925-0480 EXPIRATION DATE: 11/30/2006
RESPS:12,000 HOURS:2,000 COSTS(000):$0
NIDDK Information Clearinghouse Customer Satisfaction Survey
FORMS: NONE
OMB NO: 0925-0483 EXPIRATION DATE: 06/30/2009
RESPS:733 HOURS:122 COSTS(000):$0
Environmental Factors in the Development of Polycystic Ovary
Syndrome
FORMS: NONE
OMB NO: 0925-0484 EXPIRATION DATE: 02/28/2007
RESPS:43,093 HOURS:43,093 COSTS(000):$0
Wave 2 National Epidemiologic Survey on Alcohol and Related
Conditions (NESARC)
FORMS: NONE
OMB NO: 0925-0486 EXPIRATION DATE: 05/31/2007
RESPS:104,000 HOURS:8,684 COSTS(000):$0
Evaluation of User Satisfaction with NIH Internet Sites
FORMS: NONE
OMB NO: 0925-0491 EXPIRATION DATE: 05/31/2007
RESPS:600 HOURS:300 COSTS(000):$0
The Jackson Heart Study: Annual Follow-up with Third Party
Respondents
FORMS: NONE
OMB NO: 0925-0493 EXPIRATION DATE: 10/31/2007
RESPS:555 HOURS:42 COSTS(000):$0
The Multi-Ethnic Study of Atherosclerosis (MESA)
FORMS: NONE
OMB NO: 0925-0501 EXPIRATION DATE: 11/30/2007
RESPS:3,030 HOURS:1,060 COSTS(000):$0
Graduate Student Training Programs Application
FORMS: NONE
OMB NO: 0925-0503 EXPIRATION DATE: 12/31/2008
RESPS:500 HOURS:500 COSTS(000):$0
Assessment of the Use of Special Funding for Research on Type 1
Diabetes
FORMS: NONE
OMB NO: 0925-0520 EXPIRATION DATE: 08/31/2006
RESPS:4,882 HOURS:387 COSTS(000):$0
National Center for Complementary and Alternative Medicine
(NCCAM) Customer Service Data Collection
FORMS: NONE
OMB NO: 0925-0522 EXPIRATION DATE: 08/31/2006
RESPS:67,527 HOURS:63,438 COSTS(000):$0
The Sister Study: Environmental and Genetic Risk Factors for
Breast Cancer
FORMS: NONE
OMB NO: 0925-0523 EXPIRATION DATE: 09/30/2006
RESPS:2 HOURS:2,887 COSTS(000):$0
Aggression Prevention Among High-Risk Early Adolescents
FORMS: NONE
OMB NO: 0925-0524 EXPIRATION DATE: 11/30/2006
RESPS:986 HOURS:441 COSTS(000):$0
Assessment for Minority Research Training Programs
FORMS: NONE
OMB NO: 0925-0525 EXPIRATION DATE: 12/31/2006
RESPS:8,602 HOURS:3,267 COSTS(000):$0
Effectiveness of the National Institute on Drug Abuse's
Publications Project
FORMS: NONE
OMB NO: 0925-0526 EXPIRATION DATE: 02/28/2007
RESPS:7,642 HOURS:910 COSTS(000):$0
Customer Satisfaction with Educational Programs and Products of
the National Cancer Institute
FORMS: NONE
OMB NO: 0925-0527 EXPIRATION DATE: 06/30/2007
RESPS:750 HOURS:248 COSTS(000):$0
Career Survey of Biomedical Researchers
FORMS: NONE
OMB NO: 0925-0528 EXPIRATION DATE: 07/31/2007
RESPS:500 HOURS:184 COSTS(000):$0
Physicians' Experience of Ethical Dilemmas and Resource
Allocation
FORMS: NONE
OMB NO: 0925-0530 EXPIRATION DATE: 06/30/2007
RESPS:2,440 HOURS:712 COSTS(000):$0
National Center for Complementary and Alternative Medicine
(NCCAM) Communications Program Planning and Evaluation
FORMS: NONE
OMB NO: 0925-0531 EXPIRATION DATE: 09/30/2007
RESPS:1,072 HOURS:1,072 COSTS(000):$0
The Impact of A Decade of the Fogarty International Research
Collaboration Award (FIRCA)
FORMS: NONE
OMB NO: 0925-0532 EXPIRATION DATE: 10/31/2007
RESPS:13,625 HOURS:1,872 COSTS(000):$0
NICHD Research Partner Satisfaction Surveys
FORMS: NONE
OMB NO: 0925-0534 EXPIRATION DATE: 08/31/2007
RESPS:3,500 HOURS:1,200 COSTS(000):$0
NIH Customer/Partner Satisfaction Survey of Modification in
Procedures for Applications and Awards of Research Project Grants
FORMS: NONE
OMB NO: 0925-0535 EXPIRATION DATE: 11/30/2007
RESPS:1,875 HOURS:625 COSTS(000):$0
Obstetrician-Gynecologists' Knowledge and Practice Patterns with
Regard to Hormone Therapy
FORMS: NONE
OMB NO: 0925-0536 EXPIRATION DATE: 09/30/2007
RESPS:185 HOURS:157 COSTS(000):$0
Career Survey of Science-Oriented Scholars
FORMS: NONE
OMB NO: 0925-0538 EXPIRATION DATE: 11/30/2007
RESPS:10,489 HOURS:4,036 COSTS(000):$0
Health Information National Trends Survey II (HINTS)
FORMS: NONE
OMB NO: 0925-0540 EXPIRATION DATE: 12/31/2007
RESPS:2,568 HOURS:759 COSTS(000):$0
Pilot Study Evaluating the Cross-Cultural Equivalency of the
Tobacco Use Supplement to the Current Population Survey
FORMS: NONE
OMB NO: 0925-0541 EXPIRATION DATE: 12/31/2007
RESPS:600 HOURS:150 COSTS(000):$0
Improving Media Coverage of Cancer: A Survey of Science and
Health Reporters
FORMS: NONE
OMB NO: 0925-0542 EXPIRATION DATE: 04/30/2008
RESPS:479 HOURS:434 COSTS(000):$0
Brain Power! The NIDA Junior Scientist Program and the Companion
Program, Brain Power! Challenge
FORMS: NONE
OMB NO: 0925-0543 EXPIRATION DATE: 03/31/2008
RESPS:1,000 HOURS:15,380 COSTS(000):$0
Longitudinal Investigation of Fertility and the Environment
FORMS: NONE
OMB NO: 0925-0547 EXPIRATION DATE: 06/30/2008
RESPS:80 HOURS:40 COSTS(000):$0
Outcome Evaluation of the Small Grants Program Research in
Cancer Control
FORMS: NONE
OMB NO: 0925-0548 EXPIRATION DATE: 06/30/2008
RESPS:400 HOURS:132 COSTS(000):$0
Survey of Colorectal Cancer Screening Policies, Programs and
Systems in U.S. Health Plans
FORMS: NONE
OMB NO: 0925-0549 EXPIRATION DATE: 09/30/2008
RESPS:1 HOURS:88 COSTS(000):$0
Evaluation of NCI's Central Institutional Review Board to
Improve Cancer Clinical Trials System.
FORMS: NONE
OMB NO: 0925-0550 EXPIRATION DATE: 07/31/2008
RESPS:275 HOURS:706 COSTS(000):$0
Inventory and Evaluation of Clinical Research Networks
FORMS: NONE
OMB NO: 0925-0551 EXPIRATION DATE: 11/30/2008
RESPS:11,735 HOURS:1,155 COSTS(000):$0
The Effectiveness of the NIH Curriculum Supplements Programs
FORMS: NONE
OMB NO: 0925-0552 EXPIRATION DATE: 11/30/2008
RESPS:1 HOURS:400 COSTS(000):$0
National Diabetes Education Program Evaluation Survey of the
Public
FORMS: NONE
OMB NO: 0925-0554 EXPIRATION DATE: 12/31/2008
RESPS:150 HOURS:50 COSTS(000):$0
Survey of Institutional Program Directors of NIGMS MORE Programs
FORMS: NONE
OMB NO: 0925-0557 EXPIRATION DATE: 01/31/2009
RESPS:14,790 HOURS:10,875 COSTS(000):$0
Health Behaviors in School-Age Children Survey
FORMS: NONE
OMB NO: 0925-0558 EXPIRATION DATE: 04/30/2009
RESPS:1,060 HOURS:662 COSTS(000):$0
Discovering the Science of Alcohol Program Field Test Data
Collection Instruments
FORMS: NONE
OMB NO: 0925-0560 EXPIRATION DATE: 03/31/2009
RESPS:5,475 HOURS:2,300 COSTS(000):$0
5 A Day Customized Survey
FORMS: NONE
OMB NO: 0925-0561 EXPIRATION DATE: 05/31/2009
RESPS:450 HOURS:756 COSTS(000):$0
Use of In-Home Test Kits in Dust Mite Allergen Reduction
FORMS: NONE
OMB NO: 0925-0562 EXPIRATION DATE: 07/31/2009
RESPS:2,500 HOURS:835 COSTS(000):$0
National Survey of Primary Care Physicians for Breast, Cervical,
Colorectal, and Lung Cancer Screening
FORMS: NONE
OMB NO: 0925-0564 EXPIRATION DATE: 07/31/2009
RESPS:1,268 HOURS:480 COSTS(000):$0
Brain Train 4 Kids
FORMS: NONE
SUBAGENCY TOTALS
ACTIVE ANNUAL ANNUAL ANNUAL
REPORTS RESPONSES HOURS COSTS($000)
67 1,420,437 1,771,420 $522
Substance Abuse and Mental Health Services Administration
OMB NO: 0930-0074 EXPIRATION DATE: 04/30/2007
RESPS:79 HOURS:14 COSTS(000):$0
Obligated Service for Mental Health Traineeships: Regulations
and Forms
FORMS: SMA-111-2
OMB NO: 0930-0078 EXPIRATION DATE: 12/31/2008
RESPS:26,829 HOURS:111,938 COSTS(000):$0
Drug Abuse Warning Network (DAWN)
FORMS: NONE
OMB NO: 0930-0080 EXPIRATION DATE: 08/31/2007
RESPS:60 HOURS:31,880 COSTS(000):$0
Substance Abuse Prevention and Treatment Block Grant (SAPTBG)
Regulations (45 CFR Part 96) and FY 2005-2007 Application Format
FORMS: NONE
OMB NO: 0930-0092 EXPIRATION DATE: 08/31/2007
RESPS:1,760,526 HOURS:353,349 COSTS(000):$87
Confidentiality of Alcohol and Drug Abuse Patient Records - 42
CFR Part 2
FORMS: NONE
OMB NO: 0930-0093 EXPIRATION DATE: 11/30/2006
RESPS:52 HOURS:38 COSTS(000):$0
Annual Census of Patient Characteristics in State and County
Mental Hospital Inpatient Services
FORMS: SMA-102
OMB NO: 0930-0104 EXPIRATION DATE: 09/30/2007
RESPS:5 HOURS:3 COSTS(000):$0
Community Mental Health Centers Construction Grantee Checklist
Form and Regulations
FORMS: SMA-101
OMB NO: 0930-0106 EXPIRATION DATE: 11/30/2008
RESPS:23,125 HOURS:6,491 COSTS(000):$0
Drug and Alcohol Services Information System
FORMS: NONE
OMB NO: 0930-0110 EXPIRATION DATE: 01/31/2007
RESPS:182,250 HOURS:86,877 COSTS(000):$0
2006 National Survey on Drug Use and Health (NSDUH)
FORMS: NONE
OMB NO: 0930-0119 EXPIRATION DATE: 07/31/2008
RESPS:9,690 HOURS:14,463 COSTS(000):$0
2004 Inventory of Mental Health Organizations, and General
Hospital Mental Health Services, and Managed Care Organizations
Survey (IMHO)
FORMS: NONE
OMB NO: 0930-0158 EXPIRATION DATE: 08/31/2006
RESPS:28,384,168 HOURS:1,788,089 COSTS(000):$2,071
Mandatory Guidelines for Federal Workplace Drug Testing Program
FORMS: NONE
OMB NO: 0930-0163 EXPIRATION DATE: 04/30/2007
RESPS:60 HOURS:960 COSTS(000):$0
Substance Abuse Prevention and Treatment Block Grant Reguations
- 45 CFR Part 96
FORMS: NONE
OMB NO: 0930-0168 EXPIRATION DATE: 07/31/2007
RESPS:59 HOURS:17,265 COSTS(000):$0
Community Mental Health Services Block Grant Application
Guidance and Instructions, FY 2005-2007
FORMS: NONE
OMB NO: 0930-0169 EXPIRATION DATE: 05/31/2007
RESPS:114 HOURS:2,166 COSTS(000):$0
Protection and Advoccy of Individuals With Mental Illness
(PAIMI) Annual Program Performance Report
FORMS: NONE
OMB NO: 0930-0172 EXPIRATION DATE: 02/28/2007
RESPS:142 HOURS:184 COSTS(000):$0
Protection and Advocacy for Individuals with Mental Illness
Regulations -- 45 CFR Part 51
FORMS: NONE
OMB NO: 0930-0195 EXPIRATION DATE: 11/30/2007
RESPS:12,600 HOURS:1,843 COSTS(000):$0
Participant Feedback Forms for the Mental Health Care Provider
Education (MHCPE) in the HIV/AIDS Program
FORMS: NONE
OMB NO: 0930-0196 EXPIRATION DATE: 06/30/2007
RESPS:11,700 HOURS:9,290 COSTS(000):$0
Pretesting of Substance Abuse Prevention and Treatment and
Mental Health Services Communications Messages
FORMS: NONE
OMB NO: 0930-0197 EXPIRATION DATE: 12/31/2007
RESPS:30,150 HOURS:15,225 COSTS(000):$0
Voluntary Customer Satisfaction Surveys to Implement Executive
Order 12862 in the Substance Abuse and Mental Health Services
Administration (SAMHSA)
FORMS: NONE
OMB NO: 0930-0205 EXPIRATION DATE: 07/31/2009
RESPS:506 HOURS:14,398 COSTS(000):$0
Annual Reports for Projects for Assistance in Transition from
Homelessness (PATH)
FORMS: NONE
OMB NO: 0930-0206 EXPIRATION DATE: 09/30/2006
RESPS:9,677 HOURS:2,035 COSTS(000):$2,524
Opioid Drugs in Maintenance and Detoxification Treatment of
Opiate Addiction - 42 CFR Part 8
FORMS: SMA-162 SMA-163 SMA-168
OMB NO: 0930-0208 EXPIRATION DATE: 01/31/2007
RESPS:337,810 HOURS:24,960 COSTS(000):$0
Government Performance and Results Act Client/Participant
Outcome Measures
FORMS: NONE
OMB NO: 0930-0209 EXPIRATION DATE: 11/30/2006
RESPS:76,431 HOURS:14,040 COSTS(000):$0
National Evaluation of the Comprehensive Community Mental Health
Services for Children and Their Families Program: Phase Three
FORMS: NONE
OMB NO: 0930-0216 EXPIRATION DATE: 10/31/2006
RESPS:23,260 HOURS:7,010 COSTS(000):$0
National Cross-Site Assessment of Addiction Technology Transfer
Centers (ATTC) Network
FORMS: NONE
OMB NO: 0930-0222 EXPIRATION DATE: 08/31/2007
RESPS:59 HOURS:1,062 COSTS(000):$0
Substance Abuse Prevention and Treatment Block Grant Synar
Report Format, FY 2005-2007
FORMS: NONE
OMB NO: 0930-0226 EXPIRATION DATE: 11/30/2007
RESPS:1,446 HOURS:8,151 COSTS(000):$0
Protocols for the Cross-Site Process Evaluation of the State
incentive Grant (SIG) Program
FORMS: NONE
OMB NO: 0930-0229 EXPIRATION DATE: 07/31/2008
RESPS:6 HOURS:18 COSTS(000):$0
Emergency Response Grants - 42 CFR Part 51
FORMS: NONE
OMB NO: 0930-0230 EXPIRATION DATE: 12/31/2008
RESPS:246 HOURS:419 COSTS(000):$0
National Outcome Measures for Substance Abuse Prevention
FORMS: NONE
OMB NO: 0930-0232 EXPIRATION DATE: 03/31/2008
RESPS:3,120 HOURS:780 COSTS(000):$0
Workplace Helpline Call Record Form
FORMS: NONE
OMB NO: 0930-0234 EXPIRATION DATE: 03/31/2009
RESPS:2,050 HOURS:135 COSTS(000):$0
Notification of Intent to Use Schedule III, IV, or V Opioid
Drugs for the Maintenance and Detoxification Treatment of Opiate
Addiction
FORMS: NONE
OMB NO: 0930-0242 EXPIRATION DATE: 09/30/2006
RESPS:319,906 HOURS:16,208 COSTS(000):$56
Regulations to Implement SAMHSA's Charitable Choice Statutory
Provisions: 42 CFR Parts 54 and 54a
FORMS: SMA-170
OMB NO: 0930-0248 EXPIRATION DATE: 10/31/2006
RESPS:789 HOURS:1,123 COSTS(000):$0
Evaluation of Program Rehabilitation and Restitution (PRR)
FORMS: NONE
OMB NO: 0930-0249 EXPIRATION DATE: 10/31/2006
RESPS:1,788 HOURS:928 COSTS(000):$0
Family Treatment Drug Court Evaluation
FORMS: NONE
OMB NO: 0930-0252 EXPIRATION DATE: 12/31/2006
RESPS:106 HOURS:53 COSTS(000):$0
Safe Schools/Healthy Students Sustainability Study
FORMS: NONE
OMB NO: 0930-0255 EXPIRATION DATE: 08/31/2007
RESPS:500 HOURS:750 COSTS(000):$0
SAMHSA Application for Peer Grant Reviewers
FORMS: NONE
OMB NO: 0930-0257 EXPIRATION DATE: 04/30/2007
RESPS:51,293 HOURS:25,262 COSTS(000):$0
National Evaluation of the Comprehensive Community Mental Health
Services for Children and Their Families Program: Phase Four
FORMS: NONE
OMB NO: 0930-0258 EXPIRATION DATE: 11/30/2007
RESPS:2,000 HOURS:334 COSTS(000):$0
Assessment of the Reach Out Now! Teach-In Initiative
FORMS: NONE
OMB NO: 0930-0261 EXPIRATION DATE: 10/31/2007
RESPS:7,354 HOURS:4,886 COSTS(000):$0
National Surey on Drug Use and Health_ Methodological Field Tests
FORMS: NONE
OMB NO: 0930-0262 EXPIRATION DATE: 11/30/2007
RESPS:1,833 HOURS:770 COSTS(000):$0
Evaluation of Buprenorphine Waiver Program: Waivered Physicians
Survey
FORMS: NONE
OMB NO: 0930-0265 EXPIRATION DATE: 05/31/2008
RESPS:51 HOURS:51 COSTS(000):$0
Survey of Medicaid Directors Regarding Medicaid Mental Health
Services and Policy
FORMS: NONE
OMB NO: 0930-0266 EXPIRATION DATE: 05/31/2008
RESPS:398,226 HOURS:81,318 COSTS(000):$0
Access to Recovery (ATR) Program
FORMS: NONE
OMB NO: 0930-0269 EXPIRATION DATE: 09/30/2007
RESPS:1,338 HOURS:335 COSTS(000):$0
Cross-Site Accountability Assessment of the Residential
Treatment for Prgnant and Postpartum Women and Their Minor
Children Program (PPW)
FORMS: NONE
OMB NO: 0930-0270 EXPIRATION DATE: 09/30/2008
RESPS:16,700 HOURS:741 COSTS(000):$0
Toolkit Protocol for the Crisis Counseling Assistance and
Training Program (CCP)
FORMS: NONE
OMB NO: 0930-0271 EXPIRATION DATE: 11/30/2008
RESPS:1,274 HOURS:9,702 COSTS(000):$0
Initiative to Reduce/Eliminate Seclusion and Restraint: 8 State
Incentive Grants and Coordinating Center
FORMS: NONE
OMB NO: 0930-0272 EXPIRATION DATE: 12/31/2008
RESPS:60 HOURS:60 COSTS(000):$0
Survey of Single State Authorities Regarding the HIV Set-Aside
of the Substance Abuse Prevention and Treatment Block Grant
FORMS: NONE
OMB NO: 0930-0274 EXPIRATION DATE: 02/28/2009
RESPS:366 HOURS:264 COSTS(000):$0
Monitoring of National Suicide Prevention Lifeline Form
FORMS: NONE
OMB NO: 0930-0275 EXPIRATION DATE: 02/28/2009
RESPS:720 HOURS:598 COSTS(000):$0
Evaluation of Networking Suicide Prevention Hotlines Followup
Assessment
FORMS: NONE
OMB NO: 0930-0276 EXPIRATION DATE: 04/30/2009
RESPS:24 HOURS:11,322 COSTS(000):$0
Cross-Site Evaluation of the National Child Traumatic Stress
Initiative (NCTSI)
FORMS: NONE
OMB NO: 0930-0277 EXPIRATION DATE: 05/31/2009
RESPS:26,894 HOURS:1,373 COSTS(000):$0
Targeted Capacity Expansion Grants for Jail Diversion Programs
FORMS: NONE
OMB NO: 0930-0278 EXPIRATION DATE: 07/31/2009
RESPS:430 HOURS:724 COSTS(000):$0
Evaluation of the Policy Academies on Chronic Homelessness
FORMS: NONE
SUBAGENCY TOTALS
ACTIVE ANNUAL ANNUAL ANNUAL
REPORTS RESPONSES HOURS COSTS($000)
48 31,727,872 2,669,885 $4,738
Agency for Health Care Research and Quality
OMB NO: 0935-0106 EXPIRATION DATE: 01/31/2008
RESPS:103,400 HOURS:16,356 COSTS(000):$515,732
Voluntary Customer Surveys Generic Clearance for the Agency for
Healthcare Research and Quality
FORMS: NONE
OMB NO: 0935-0110 EXPIRATION DATE: 02/29/2008
RESPS:36,264 HOURS:20,922 COSTS(000):$0
2004 - 2006 Medical Expenditure Panel Survey - Insurance
Componenet (MEPS-IC)
FORMS: NONE
OMB NO: 0935-0117 EXPIRATION DATE: 02/28/2007
RESPS:285 HOURS:87 COSTS(000):$0
Surveys of Employee Benefit Managers of Large National Employers
Concerning Dissemination Effectiveness of Health Services
Research Information
FORMS: NONE
OMB NO: 0935-0118 EXPIRATION DATE: 02/28/2007
RESPS:83,700 HOURS:249,848 COSTS(000):$0
Medical Expenditure Panel Survey Household Component and Medical
Provider Component (MEPS-HC and MEPS-MPC 2004 and 2005)
FORMS: NONE
OMB NO: 0935-0122 EXPIRATION DATE: 11/30/2007
RESPS:1,500 HOURS:250 COSTS(000):$0
AHRQ Grants Reporting System
FORMS: NONE
OMB NO: 0935-0124 EXPIRATION DATE: 01/31/2008
RESPS:10,500 HOURS:5,200 COSTS(000):$0
Questionnaire and Data Collection Testing, Evaluation, and
Research for the Agency for Healthcare Research and Quality
FORMS: NONE
OMB NO: 0935-0125 EXPIRATION DATE: 07/31/2008
RESPS:960 HOURS:403 COSTS(000):$0
National Study of the Hospital Adverse Event Reporting Survey
FORMS: NONE
SUBAGENCY TOTALS
ACTIVE ANNUAL ANNUAL ANNUAL
REPORTS RESPONSES HOURS COSTS($000)
7 236,609 293,066 $515,732
Office of Assistant Secretary for Health
OMB NO: 0937-0025 EXPIRATION DATE: 09/30/2006
RESPS:10,000 HOURS:4,000 COSTS(000):$0
Reference Request for Applicants to the U.S. Public Health
Service Commissioned Corps
FORMS: PHS-50 PHS-1813
OMB NO: 0937-0166 EXPIRATION DATE: 08/31/2006
RESPS:50,000 HOURS:50,000 COSTS(000):$0
42 C.F.R. Subpart B: Sterilization of Persons in Federally
Assisted Family Planning Projects
FORMS: NONE
OMB NO: 0937-0191 EXPIRATION DATE: 02/29/2008
RESPS:22 HOURS:4,400 COSTS(000):$0
Application Packets for Real Property for Public Health Purposes
FORMS: HHS-696
OMB NO: 0937-0198 EXPIRATION DATE: 03/31/2009
RESPS:3,800 HOURS:400 COSTS(000):$0
Public Health Service Policies on Research Misconduct (42 CFR
Part 93)
FORMS: PHS-6349
OMB NO: 0937-0200 EXPIRATION DATE: 06/30/2007
RESPS:73,560 HOURS:220,980 COSTS(000):$0
HHS Payment Management System Forms PMS-270 - Request for
Advance or Reimbursement and PMS-272 - Federal Cast Transaction
Report
FORMS: 270 272
SUBAGENCY TOTALS
ACTIVE ANNUAL ANNUAL ANNUAL
REPORTS RESPONSES HOURS COSTS($000)
5 137,382 279,780 $0
Centers for Medicare and Medicaid Services
OMB NO: 0938-0008 EXPIRATION DATE: 05/31/2009
RESPS:957,204,707 HOURS:46,383,364 COSTS(000):$0
Health Insurance Common Claims Form and Supporting Regulations
at 42 CFR Part 424, Subpart C
FORMS: CMS-1490S CMS-1490U CMS-1500(12-90)
OMB NO: 0938-0022 EXPIRATION DATE: 04/30/2007
RESPS:7,310 HOURS:1,311,060 COSTS(000):$0
Home Health Agency Cost Report and Supporting Regulations in 42
CFR 413.20, 413.24, 413.106
FORMS: CMS-1728-94
OMB NO: 0938-0023 EXPIRATION DATE: 07/31/2008
RESPS:200 HOURS:50 COSTS(000):$0
Attending Physicians Statement and Documentation of Medicare
Emergency and Supporting Regulations in 42 CFR 424.103
FORMS: CMS-1771
OMB NO: 0938-0025 EXPIRATION DATE: 08/31/2006
RESPS:14,000 HOURS:5,833 COSTS(000):$0
Request for Termination of Premium-Hospital and/or Supplementary
Medical Insurance and Supporting Regulations in 42 CFR 406.28 &
407.27
FORMS: CMS-1763
OMB NO: 0938-0027 EXPIRATION DATE: 02/28/2009
RESPS:98 HOURS:172 COSTS(000):$0
Request for Certification as Supplier of Portable X-Ray and
Portable X-Ray Survey Report Form
FORMS: 1880-1882
OMB NO: 0938-0033 EXPIRATION DATE: 05/31/2007
RESPS:6,860,000 HOURS:1,629,000 COSTS(000):$0
Request for Review of Part B Medicare Claim and Supporting
Regulations in 42 CFR Sec. 405.807
FORMS: CMS-1964
OMB NO: 0938-0035 EXPIRATION DATE: 07/31/2009
RESPS:6,600 HOURS:2,366 COSTS(000):$0
Social Security Office (SSO) Report of State Buy-in Problems
FORMS: CMS-1957
OMB NO: 0938-0037 EXPIRATION DATE: 01/31/2008
RESPS:618 HOURS:61,800 COSTS(000):$0
Outpatient Rehabilitation Cost Report and Supporting Regulations
in 42 CFR 413.20 and 413.24
FORMS: CMS-2088-92
OMB NO: 0938-0041 EXPIRATION DATE: 11/30/2006
RESPS:17,350 HOURS:6,446 COSTS(000):$0
Third Party Premium Billing Request and Supporting Regulations
in 42 CFR 408.6 and 408.202
FORMS: CMS-2384
OMB NO: 0938-0042 EXPIRATION DATE: 04/30/2007
RESPS:240,000 HOURS:60,010 COSTS(000):$0
Request for Medicare Payment -- Ambulance and Supporting
Regulations in 42 CFR Sections 410.1, 410.40, 424.124, 424.601,
414.605, 414.610, 414.615, 414.620, 414.625, and 424.32
FORMS: CMS-1491
OMB NO: 0938-0045 EXPIRATION DATE: 11/30/2006
RESPS:60,000 HOURS:15,000 COSTS(000):$0
Request for Reconsideration of Part A Medicare Claim and
Supporting Regulations in 42 CFR, 405.711
FORMS: CMS-2649
OMB NO: 0938-0046 EXPIRATION DATE: 06/30/2007
RESPS:100,000 HOURS:75,000 COSTS(000):$0
End Stage Renal Disease Medical Evidence Report Medicare
Entitlement and/or Patient Registration and Supporting
Regulations in 42 CFR, 405.2133; PL 95-292; CFR Parts....
FORMS: CMS-2728-ESRD
OMB NO: 0938-0050 EXPIRATION DATE: 05/31/2008
RESPS:6,111 HOURS:4,046,782 COSTS(000):$0
Hospitals and Health Care Complex Cost Report
FORMS: 2552-96
OMB NO: 0938-0062 EXPIRATION DATE: 01/31/2007
RESPS:177,271,815 HOURS:6,841,538 COSTS(000):$0
Intermediate Care Facility for the Mentally Retarded or Persons
with Related Conditions ICF/MR Survey Report Form (3070G-I) and
Supporting Regulations at 42CFR 442.30, 483.410, 483.420,...
FORMS: CMS-3070G-I
OMB NO: 0938-0065 EXPIRATION DATE: 10/31/2008
RESPS:495 HOURS:866 COSTS(000):$0
Outpatient Physical Therapy Speech Pathology Survey Report and
Supporting Regulation in 42 CFR 485.701-485.729
FORMS: 1856 1893
OMB NO: 0938-0067 EXPIRATION DATE: 06/30/2008
RESPS:224 HOURS:18,144 COSTS(000):$0
Quarterly Medicaid Statement of Expenditures for the Medical
Assistance Program
FORMS: CMS-64
OMB NO: 0938-0074 EXPIRATION DATE: 12/31/2008
RESPS:698 HOURS:1,222 COSTS(000):$0
Request for Certification as Rural Health Clinic and Rural
Health Clinic Survey Report Form and Supporting Regulations in
42 CFR 491.1-491.11
FORMS: 0029-0030
OMB NO: 0938-0080 EXPIRATION DATE: 10/31/2006
RESPS:60,000 HOURS:26,000 COSTS(000):$0
Application for Health Insurance Benefits Under Medicare for
Individual with Chronic Renal Disease and Supporting Regulations
in 42 CFR 406.7 and .13
FORMS: CMS-43
OMB NO: 0938-0086 EXPIRATION DATE: 12/31/2008
RESPS:125,000 HOURS:62,500 COSTS(000):$0
Disclosure of Ownership and Financial Control Interest Statement
and Supporting Regulations Contained in 42 CFR 420.200-.206 and
455.100-.106
FORMS: CMS-1513
OMB NO: 0938-0101 EXPIRATION DATE: 09/30/2008
RESPS:224 HOURS:7,616 COSTS(000):$0
Medicaid Program Budget Report, and Supporting Regs.
FORMS: CMS-37
OMB NO: 0938-0102 EXPIRATION DATE: 08/31/2006
RESPS:108 HOURS:4,860 COSTS(000):$0
Organ Procurement Organization/Histcompatibility Laboratory
Statement of Reimbursable Costs, Manual Instructions and
Supporting Regulations Contained in 42 CFR 413.20 and 413.24
FORMS: CMS-216
OMB NO: 0938-0107 EXPIRATION DATE: 06/30/2008
RESPS:3,000 HOURS:150,000 COSTS(000):$0
Independent Rural Health Center/Freestanding Federally Qualified
Health Center Cost Report and Supp. Regs in 42 CFR Sections
413.20 and 413.24
FORMS: CMS-222
OMB NO: 0938-0146 EXPIRATION DATE: 09/30/2006
RESPS:110 HOURS:2,640 COSTS(000):$0
State Medicaid Eligibility Quality Control Samplling Plan and
Supporting Regulations in 42 CFR 431.800 - 431.865
FORMS: CMS-317
OMB NO: 0938-0147 EXPIRATION DATE: 09/30/2006
RESPS:12 HOURS:5,280 COSTS(000):$0
State Medicaid Eligibility Control (MEQC) Sample Selection Lists
and Supporting Regulations at 42 CFR 431.800 431.865
FORMS: CMS-319
OMB NO: 0938-0151 EXPIRATION DATE: 08/31/2008
RESPS:10,500 HOURS:5,250 COSTS(000):$0
Laboratory Personnel Report (CLIA) and Supporting Regulations in
42 CFR 493.1 - 493.2001
FORMS: CMS-209
OMB NO: 0938-0155 EXPIRATION DATE: 03/31/2007
RESPS:14 HOURS:476 COSTS(000):$0
Municipal Health Services Cost Report Form and Supporting
Regulations 42 CFR 405.2470
FORMS: CMS-255
OMB NO: 0938-0165 EXPIRATION DATE: 08/31/2006
RESPS:225 HOURS:7,860 COSTS(000):$0
Prepaid Health Plan Cost Report
FORMS: CMS-276
OMB NO: 0938-0193 EXPIRATION DATE: 07/31/2007
RESPS:56 HOURS:560 COSTS(000):$0
Transmittal and Notice of Approval of State Plan Material and
Supporting Regulations in 42 CFR 430.10-430.20 and 440.167
FORMS: CMS-179
OMB NO: 0938-0202 EXPIRATION DATE: 07/31/2008
RESPS:1,231 HOURS:573,646 COSTS(000):$0
Home Office Cost Statement and Supporting Regulations in 42 CFR
413.17 and 413.20
FORMS: 287
OMB NO: 0938-0214 EXPIRATION DATE: 05/31/2009
RESPS:124,553,682 HOURS:1,611,303 COSTS(000):$0
Medicare Secondary Payer Informaiton Collection and Supp. Regs.
in 42 CFR 489.20, 411.25, 489.2
FORMS: 250-254
OMB NO: 0938-0236 EXPIRATION DATE: 06/30/2007
RESPS:3,592 HOURS:704,032 COSTS(000):$0
Independent Renal Dialysis Facility Cost Report and Supporting
Regulations 42 CFR 413.20 and 42 CFR 413.24
FORMS: CMS-265-94
OMB NO: 0938-0242 EXPIRATION DATE: 03/31/2007
RESPS:27,900 HOURS:2,325 COSTS(000):$0
Fire Safety Survey Report Forms and Supporting Regulations in 42
CFR 488.26 and 442.30
FORMS: CMS-2786M 2786R 2786S 2786T 2786U 2786V 2786W 2786X 2786Y
OMB NO: 0938-0245 EXPIRATION DATE: 09/30/2006
RESPS:10,000 HOURS:2,500 COSTS(000):$0
Request for Enrollment in Supplementary Medical Insurance and
Supporting Regulations in 42 CFR 407.10 & 407.11
FORMS: CMS-4040 CMS-4040-SP
OMB NO: 0938-0246 EXPIRATION DATE: 09/30/2006
RESPS:102 HOURS:22,515 COSTS(000):$0
Certification of Medicaid Eligibilty Quality Control (MEQC)
Payment Error Rates and Supporting Regulations at 42 CFR.431.800
through 431.865
FORMS: CMS-301
OMB NO: 0938-0251 EXPIRATION DATE: 09/30/2007
RESPS:50,000 HOURS:12,500 COSTS(000):$0
Application for Hospital Insurance and Supporting Regulations in
42 CFR 406.7
FORMS: CMS-18F5
OMB NO: 0938-0266 EXPIRATION DATE: 02/29/2008
RESPS:4,312 HOURS:2,381 COSTS(000):$0
Ambulatory Surgical Center (ASC) Health Insurance Benefits
Agreement Form, Request for Certification, Survey Report and
Supporting Regulations in 42 CFR 416.41, 416.43, 416.47, and...
FORMS: CMS-377 CMS-378 CMS-R-54 CMS-370
OMB NO: 0938-0267 EXPIRATION DATE: 06/30/2009
RESPS:630 HOURS:300,046 COSTS(000):$0
Comprehensive Outpatient Rehabilitation Facility (CORF)
Eligibility and Survey Forms and Information Collection
Requirements in 42 CFR 485.56, 485.58, 485.60, 485.64...
FORMS: 359 360 R-55
OMB NO: 0938-0269 EXPIRATION DATE: 02/28/2009
RESPS:822 HOURS:411 COSTS(000):$0
Request for Accelerated Payments Supporting Regulations in 42
CFR, section 412.116 & 413.64
FORMS: CMS-9042
OMB NO: 0938-0270 EXPIRATION DATE: 09/30/2007
RESPS:500 HOURS:1,000 COSTS(000):$0
The Financial Statement of Debtor and Supporting Regulations in
42 CFR, Section 405.376
FORMS: CMS-379
OMB NO: 0938-0272 EXPIRATION DATE: 12/31/2006
RESPS:277 HOURS:20,775 COSTS(000):$0
Annual Report on Home and Community-Based Services Waivers and
Supporting Regulations in 42 CFR 440.180 and 441.300-310
FORMS: CMS-372(S)
OMB NO: 0938-0273 EXPIRATION DATE: 12/31/2008
RESPS:2,960 HOURS:740 COSTS(000):$0
Identification of Extension Units of Outpatient Physical
Therapy/Outpatient Speech Pathology Providers and Support Regs.
FORMS: CMS-381
OMB NO: 0938-0279 EXPIRATION DATE: 11/30/2008
RESPS:174,461,278 HOURS:1,997,581 COSTS(000):$0
Medicare Uniform Institutional Provider Bill
FORMS: CMS-1450
OMB NO: 0938-0287 EXPIRATION DATE: 12/31/2008
RESPS:27 HOURS:81 COSTS(000):$0
Withholding Medicare Payments to Recover Medicaid Overpayments
and Supporting Regulations in 42 CFR 447.31
FORMS: R-21
OMB NO: 0938-0296 EXPIRATION DATE: 04/30/2007
RESPS:125 HOURS:6,000 COSTS(000):$0
Provider Reimbursement Manual, Part 1 - Chapter 27, Sections
2721, 2722 and 2725, Request for Exception to End Stage Renal
Disease Composite Rates and Supporting Regulations in 42 CFR..
FORMS: CMS-9044
OMB NO: 0938-0301 EXPIRATION DATE: 11/30/2008
RESPS:35,904 HOURS:603,306 COSTS(000):$0
Medicare Provider Cost Report Reimbursement Questionnaire and
Supporting Regulations in 42 CFR 413.20, 413.24, and 415.60
FORMS: CMS-339
OMB NO: 0938-0302 EXPIRATION DATE: 09/30/2006
RESPS:2,311 HOURS:10,821,923 COSTS(000):$0
Information Collection Requirements in the Hospice Conditions
for Coverage. The following regulations are affected: 42CFR
418.22; 418.24; 418.28; 418.56(b),(e)(1),(e)(3); 418.58;......
FORMS: CMS-R-30
OMB NO: 0938-0313 EXPIRATION DATE: 08/31/2007
RESPS:2,286 HOURS:572 COSTS(000):$0
Hospice Request for Certification in the Medicare Program and
Supporting Regulations contained in 42 CFR Part 489.11 and 489.20
FORMS: CMS-417
OMB NO: 0938-0328 EXPIRATION DATE: 01/31/2008
RESPS:6,085 HOURS:5,511,544 COSTS(000):$0
Hospital Conditions of Participation (COP) and Supporting
Regulations in 42 CFR, Sections 482.12, 482.13, 482.21, 482.22,
482.27, 482.30, 482.41, 482.43, 482.45, 482.53.....
FORMS: CMS-R-48
OMB NO: 0938-0334 EXPIRATION DATE: 01/31/2007
RESPS:3,305 HOURS:8,580 COSTS(000):$0
Conditions for Coverage for Rural Health Clinics -- 42 CFR
Section 491.9 and 491.10
FORMS: CMS-R-38
OMB NO: 0938-0338 EXPIRATION DATE: 07/31/2008
RESPS:602 HOURS:1,505 COSTS(000):$0
Conditions of Participation for Portable X-ray Suppliers and
Supporting Regulations in 42 CFR Sections 486.104, 486.106,
486.110
FORMS: CMS-R-43
OMB NO: 0938-0345 EXPIRATION DATE: 06/30/2009
RESPS:212 HOURS:2,120 COSTS(000):$64
Medicaid Statistical Information System
FORMS: CMS-R-284
OMB NO: 0938-0354 EXPIRATION DATE: 03/31/2009
RESPS:56 HOURS:1,568 COSTS(000):$15
Annual Early and Periodic Screening, Diagnostic and Treatment
Services (EPSDT) Participation Report
FORMS: 416
OMB NO: 0938-0355 EXPIRATION DATE: 11/30/2006
RESPS:24,150 HOURS:3,864 COSTS(000):$0
Home Health Agency Survey and Deficiencies Report, Home Health
Functional Assessment Instrument and Supporting Regulations in
42 CFR 488.26 and 442.30
FORMS: CMS-1515 CMS-1572
OMB NO: 0938-0358 EXPIRATION DATE: 03/31/2007
RESPS:2,610 HOURS:652 COSTS(000):$0
Psychiatric Unit Criteria Work Sheet, Rehabilitation Unit
Criteria Work Sheet and Rehabilitation Hospital Criteria Work
Sheet, and Supporting Regulations at 42 CFR 488.26
FORMS: 437 437A 437B
OMB NO: 0938-0359 EXPIRATION DATE: 03/31/2008
RESPS:397,500 HOURS:11,925 COSTS(000):$0
Medical Records Review Under PPS and Supporting Regulations at
42 CFR 412.40-412.52
FORMS: CMS-R-50
OMB NO: 0938-0360 EXPIRATION DATE: 01/31/2007
RESPS:1,320 HOURS:440 COSTS(000):$0
End Stage Renal Disease Application and Survey and Certification
Report Form and Supporting Regulations 42 CFR 488.60
FORMS: CMS-3427
OMB NO: 0938-0365 EXPIRATION DATE: 05/31/2007
RESPS:7,422 HOURS:854,891 COSTS(000):$0
Home Health Medicare Conditions of Participation (CoP)
Information Collection Requirements as outlined in Regulations
-- 42 CFR 484.10, 484.12, 484.14, 484.16,....
FORMS: CMS-R-39
OMB NO: 0938-0372 EXPIRATION DATE: 01/31/2008
RESPS:7,400 HOURS:617 COSTS(000):$0
ESRD Beneficiary Selection and Supporting Regulations Contained
in 42 CFR 414.330
FORMS: CMS-382
OMB NO: 0938-0373 EXPIRATION DATE: 10/31/2007
RESPS:6,000 HOURS:1,500 COSTS(000):$0
Medicare Participating Physician or Supplier Agreement
FORMS: CMS-460
OMB NO: 0938-0378 EXPIRATION DATE: 09/30/2007
RESPS:200 HOURS:100 COSTS(000):$0
The Medicare/Medicaid Psychiatric Hospital Survey Data Contained
in 42 CFR and Supporting Regulations in 42 CFR 482.60, 482.61,
and 482.62
FORMS: CMS-724
OMB NO: 0938-0379 EXPIRATION DATE: 07/31/2009
RESPS:490 HOURS:1,225 COSTS(000):$0
Hospice Survey and Deficiencies Report Form
FORMS: CMS-643
OMB NO: 0938-0386 EXPIRATION DATE: 10/31/2006
RESPS:4,297 HOURS:148,785 COSTS(000):$0
Conditions for Coverage of Suppliers of End Stage Renal Disease
(ESRD) Services and Supporting Regulations Contained in 42 CFR
405.2100-.2171
FORMS: CMS-R-52
OMB NO: 0938-0391 EXPIRATION DATE: 03/31/2009
RESPS:60,000 HOURS:120,000 COSTS(000):$0
Statement of Deficiencies and Plan of Correction
FORMS: CMS-2567
OMB NO: 0938-0426 EXPIRATION DATE: 08/31/2006
RESPS:3,729 HOURS:60,919 COSTS(000):$0
Information Collection Requirements in HSQ-110, Acquisition,
Protection and Disclosure of Peer Review Organization
Information and Supporting Regulations in 42 CFR, Section
480.104, 480.105,..
FORMS: CMS-R-70
OMB NO: 0938-0429 EXPIRATION DATE: 07/31/2007
RESPS:2 HOURS:20 COSTS(000):$0
Imposition of Cost Sharing Charges Under Medicaid and Supporting
Regulations contained in 42 CFR Section 447.53
FORMS: CMS-R-0053
OMB NO: 0938-0443 EXPIRATION DATE: 08/31/2006
RESPS:5,228 HOURS:2,822 COSTS(000):$0
Information Collection Requirements in 42 CFR 478.18, 478.34,
478.36, and 478.42, QIO Reconsiderations and Appeals
FORMS: CMS-R-72
OMB NO: 0938-0444 EXPIRATION DATE: 10/31/2008
RESPS:1,060 HOURS:22,684 COSTS(000):$0
Information Collection Requirements in Final Peer Review
Organizations Sanction Regulations 42 CFR Sections 1004.40,
1004.50, 1004.50, 1004.60, 1004.70
FORMS: R-65
OMB NO: 0938-0445 EXPIRATION DATE: 06/30/2008
RESPS:6,036 HOURS:81,818 COSTS(000):$0
QIO Assumption of Responsibilities and Supp. Regs. in 42 CFR
Sections 412.44, 412.46, 431.630, 476.71, 476.74, 476.78
FORMS: CMS-R-71
OMB NO: 0938-0447 EXPIRATION DATE: 01/31/2007
RESPS:4,360 HOURS:34,880 COSTS(000):$0
End Stage Renal Disease Medical Information System ESRD Facility
Survey and Supporting Regulations in 42 CFR 405.2133
FORMS: CMS-2744
OMB NO: 0938-0448 EXPIRATION DATE: 01/31/2007
RESPS:69,760 HOURS:34,880 COSTS(000):$0
End Stage Renal Disease Death Notification, P.L. 95-292; 42 CFR
405.;2133; 45 CFR 5,5b; 20 CFR Parts 401, 422E
FORMS: CMS-2746
OMB NO: 0938-0449 EXPIRATION DATE: 09/30/2008
RESPS:132 HOURS:7,930 COSTS(000):$0
Home & Community Based Waiver Requests and Supporting
Regulations; 42 CFR 440.180, 441.300-.310
FORMS: CMS-8003
OMB NO: 0938-0454 EXPIRATION DATE: 08/31/2006
RESPS:689,572 HOURS:441,793 COSTS(000):$0
Physician Certifications/Recertifications in Skilled Nursing
Facilities (SNFs) Manual Instructions and Supporting Regulation
in 42 CFR 424.20
FORMS: CMS-R-5
OMB NO: 0938-0456 EXPIRATION DATE: 11/30/2006
RESPS:1,225 HOURS:2,450 COSTS(000):$0
Indirect Medical Education (IME) and Supporting Regulations 42
CFR 412.105
FORMS: CMS-R-64
OMB NO: 0938-0463 EXPIRATION DATE: 04/30/2007
RESPS:13,000 HOURS:2,480,000 COSTS(000):$0
Skilled Nursing Facility and Silled Nursing Facility Cost Report
and Supporting Regulations in 42 CFR 413.20, 413.24, and 413.106
FORMS: CMS-2540-96
OMB NO: 0938-0467 EXPIRATION DATE: 03/31/2009
RESPS:54 HOURS:124,054 COSTS(000):$0
Income and Eligibility Verification System Reporting and
Supporting Regs.
FORMS: R-0074
OMB NO: 0938-0469 EXPIRATION DATE: 09/30/2008
RESPS:370 HOURS:62 COSTS(000):$0
The Fiscal Soundness Reporting Requirements
FORMS: CMS-906
OMB NO: 0938-0470 EXPIRATION DATE: 04/30/2007
RESPS:55 HOURS:5,958 COSTS(000):$0
Qualification Application; Medicare+Choice Application of HMOs,
PPOs, & State Licensed PSOs; Medicare+Choice Application for
Federally Waived PSOs; Medicare+Choice Application for Medicare..
FORMS: CMS-901A 901B 901C
OMB NO: 0938-0477 EXPIRATION DATE: 09/30/2008
RESPS:40 HOURS:160 COSTS(000):$0
Payment Adjustment for Sole Community Hospitals and Supporting
Regs. in 42 CFR 412.92
FORMS: CMS-R-79
OMB NO: 0938-0484 EXPIRATION DATE: 09/30/2006
RESPS:1,100 HOURS:275 COSTS(000):$0
Emergency and Foreign Hospital Services - Beneficiary Statement
in Canadian Travel Claims and Supporting Regulations in 42 CFR,
Section 424.123
FORMS: CMS-R-96
OMB NO: 0938-0501 EXPIRATION DATE: 04/30/2007
RESPS:4,300 HOURS:717 COSTS(000):$0
Medicare Qualification Statement for Federal Employees and
Supporting Regulations in 42 CFR 406.15
FORMS: CMS-565
OMB NO: 0938-0502 EXPIRATION DATE: 03/31/2009
RESPS:2,700,000 HOURS:472,259 COSTS(000):$0
Medicaid - Determining Third Party Liability (TPL) State Plan
Preprint and Supporting Regulation in 42 CFR 433.138
FORMS: CMS-R-0107
OMB NO: 0938-0512 EXPIRATION DATE: 12/31/2006
RESPS:58 HOURS:116 COSTS(000):$0
Organ Procurement Organization's Health Insurance Benefits
Agreement and Supporting Regulations 42 CFR 486.301-486.348
FORMS: CMS-576A
OMB NO: 0938-0526 EXPIRATION DATE: 06/30/2007
RESPS:53 HOURS:1 COSTS(000):$0
Quality Improvement (formerly Peer Review) Organization
Contracts: Solicitation of Statement of Interest from In-State
Organizations, General Notice and Supporting...
FORMS: CMS-R-118
OMB NO: 0938-0534 EXPIRATION DATE: 09/30/2008
RESPS:1,200,000 HOURS:240,000 COSTS(000):$0
Attending Physician's Certification of Medical Necessity for
Home Oxygen Therapy and Supporting Regulations 42 CFR 410.38 and
42 CFR 424.5
FORMS: CMS-484
OMB NO: 0938-0544 EXPIRATION DATE: 03/31/2009
RESPS:12,500 HOURS:6,250 COSTS(000):$0
Survey Report Form Clinical Laboratory Improvement Amendments
(CLIA) and supporting regulations in 42 CFR 493.1-493.2001
FORMS: CMS-1557
OMB NO: 0938-0564 EXPIRATION DATE: 11/30/2006
RESPS:13,311 HOURS:1 COSTS(000):$0
Proper Claim Not Filed and Supporting Regulation Contained in 42
CFR 411.32(c)
FORMS: CMS-R-136
OMB NO: 0938-0565 EXPIRATION DATE: 12/31/2008
RESPS:341,065 HOURS:1,986,810 COSTS(000):$0
IRS/SSA/CMS Data Match and Supporting Regulations in 42 CFR
Sections 411.20-411.206
FORMS: CMS-R-137
OMB NO: 0938-0566 EXPIRATION DATE: 05/31/2007
RESPS:21,171,480 HOURS:1,764,290 COSTS(000):$0
Advance Beneficiary Notice and Supporting Regulations in 42 CFR
411.404, 411.406, and 411.408
FORMS: CMS-R-131
OMB NO: 0938-0568 EXPIRATION DATE: 03/31/2007
RESPS:49,500 HOURS:50,325 COSTS(000):$0
Medicare Current Beneficiary Survey (MCBS): Rounds 38-46
FORMS: CMS-P-0015A
OMB NO: 0938-0573 EXPIRATION DATE: 11/30/2008
RESPS:500 HOURS:500 COSTS(000):$0
Medicare Geographic Classification Review Board Procedures and
Criteria and Supporting Regulations in 42 CFR, Section 412.256
FORMS: R-138
OMB NO: 0938-0575 EXPIRATION DATE: 08/31/2006
RESPS:50 HOURS:150 COSTS(000):$0
Analysis of Malpractice Premium Data
FORMS: CMS-R-143
OMB NO: 0938-0578 EXPIRATION DATE: 07/31/2007
RESPS:2,280 HOURS:54,780 COSTS(000):$0
Medicaid Drug Rebate Program - Manufacturers and Supporting
Regulation at 42 CFR 447.534
FORMS: CMS-367 367A 367C
OMB NO: 0938-0579 EXPIRATION DATE: 08/31/2006
RESPS:20 HOURS:455 COSTS(000):$0
Business Proposal Formats for Quality Improvement Organizations
(QIOs) - previously known as PEER REVIEW ORGANIZATIONS (PROs)
FORMS: CMS-FORM-718BP 719BP 720BP 721BP SUM STAFFING SC1 SC2
OMB NO: 0938-0581 EXPIRATION DATE: 09/30/2007
RESPS:16,000 HOURS:20,000 COSTS(000):$0
Clinical Laboratory Improvement Amendments Application Form 42
CFR 493.1-.2001
FORMS: CMS-116
OMB NO: 0938-0582 EXPIRATION DATE: 07/31/2009
RESPS:204 HOURS:9,389 COSTS(000):$0
State Drug Rebate (Medicaid)
FORMS: CMS-368 CMS-R-144
OMB NO: 0938-0599 EXPIRATION DATE: 11/30/2007
RESPS:50 HOURS:4,500 COSTS(000):$0
CLIA Budget Workload Reports and Supporting Regulations
Contained in 42 CFR 493.1-.2001
FORMS: CMS-102 CMS-105
OMB NO: 0938-0600 EXPIRATION DATE: 12/31/2008
RESPS:193,200 HOURS:579,600 COSTS(000):$0
Medicare Credit Balance Reporting Requirements and Supporting
Regulations in 42 CFR 405.371, 405.378, and 413.20
FORMS: CMS-838
OMB NO: 0938-0610 EXPIRATION DATE: 10/31/2008
RESPS:33,096 HOURS:924,120 COSTS(000):$0
Advanced Directives (Medicare and Medicard) - BDP-718
FORMS: CMS-R-10
OMB NO: 0938-0612 EXPIRATION DATE: 06/30/2007
RESPS:111,354,920 HOURS:9,823,934 COSTS(000):$0
Information Collection Requirements (ICR) Contained in the
Clinical Laboratory Improvement Amendments (CLIA) Regulations 42
CFR Part 493.801, 493.803, 493.1232, 493.1233, 493.1234,...
FORMS: CMS-R-26
OMB NO: 0938-0618 EXPIRATION DATE: 04/30/2008
RESPS:40 HOURS:3,200 COSTS(000):$0
Limitations on Provider Related Donations and Health Care
Related Taxes, etc.
FORMS: R-148
OMB NO: 0938-0626 EXPIRATION DATE: 09/30/2006
RESPS:10,000 HOURS:1,250 COSTS(000):$0
Authorization Agreement for Electronic Funds Transfer
FORMS: CMS-588
OMB NO: 0938-0653 EXPIRATION DATE: 09/30/2006
RESPS:11,250 HOURS:2,813 COSTS(000):$0
Post Laboratory Survey Questionnaire--Laboratory, and Supporting
Regulations in 42 CFR 493.1771, 493.1773, and 493.1777
FORMS: CMS-668B
OMB NO: 0938-0657 EXPIRATION DATE: 09/30/2006
RESPS:36 HOURS:108 COSTS(000):$0
End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report
Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR
405.2112
FORMS: CMS-685
OMB NO: 0938-0658 EXPIRATION DATE: 09/30/2006
RESPS:36 HOURS:1,080 COSTS(000):$0
End-Stage Renal Disease (ESRD) Network Business Proposal Forms
and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112
FORMS: CMS-684A-684I
OMB NO: 0938-0667 EXPIRATION DATE: 01/31/2007
RESPS:5,600 HOURS:1 COSTS(000):$0
Examination and Treatment for Emergency Medical Conditions and
Women in Labor (EMTALA), 42 CFR 482.12, 488.18, 489.20, and
489.24, & HCFA-1005-IFC, PPS for Hospital Outpatient Services,...
FORMS: CMS-R-142
OMB NO: 0938-0676 EXPIRATION DATE: 03/31/2007
RESPS:3,744 HOURS:139,560 COSTS(000):$350
Reconciliation of State Invoice and Prior Quarter Adjustment
Statement
FORMS: CMS-304 304A
OMB NO: 0938-0679 EXPIRATION DATE: 09/30/2008
RESPS:5,400,000 HOURS:1,080,000 COSTS(000):$0
Durable Medical Equipment Regional Carrier, Certificates of
Medical Necessity
FORMS: 846-849 854 10125 10126
OMB NO: 0938-0685 EXPIRATION DATE: 04/30/2009
RESPS:400,000 HOURS:1,000,000 COSTS(000):$0
Medicare Enrollment Application
FORMS: CMS-855A 855B 855I 855R 855S
OMB NO: 0938-0686 EXPIRATION DATE: 05/31/2008
RESPS:76 HOURS:768 COSTS(000):$0
Granting and Withedrawal of Deeming Authority to Private
Nonprofit Accreditation Organizations and of State Exemption
Under State Laboratory Programs and Supporting Regs
FORMS: R-185
OMB NO: 0938-0688 EXPIRATION DATE: 02/28/2007
RESPS:59 HOURS:118 COSTS(000):$0
Conditions of Coverage for Organ Procurement Organizations
(OPOs) and Supporting Regulations in 42 CFR, Section 486.304,
486.306, 486.307, 486.310, 486.316, 486.218, and 486.325
FORMS: CMS-R-13
OMB NO: 0938-0691 EXPIRATION DATE: 08/31/2006
RESPS:100 HOURS:100 COSTS(000):$0
Medicare Disproportionate Share Adjustment Procedures and
Criteria and Supporting Regulations in 42 CFR 412.106
FORMS: CMS-R-194
OMB NO: 0938-0692 EXPIRATION DATE: 03/31/2009
RESPS:12,500,000 HOURS:208,333 COSTS(000):$0
Important Message From Medicare
FORMS: CMS-R-193
OMB NO: 0938-0697 EXPIRATION DATE: 01/31/2007
RESPS:57 HOURS:342 COSTS(000):$0
Medicaid Report on Payables and Receivables
FORMS: CMS-R199
OMB NO: 0938-0701 EXPIRATION DATE: 01/31/2007
RESPS:1,569 HOURS:429,598 COSTS(000):$0
Health Plan Employer Data and Information Set (HEDIS) and Health
Outcome Survey (HOS) and Supporting Regulations at 42 CFR 422.152
FORMS: CMS-R-200
OMB NO: 0938-0702 EXPIRATION DATE: 08/31/2006
RESPS:43,501,897 HOURS:531,149 COSTS(000):$0
Information Collection Requirements Referenced in HIPAA, Title
1, for the Group Market, Supporting Regulations at 45 CFR
146.111, 146.115, 146.117, 146.150, 146.152, 146.160, and
146.180, and...
FORMS: CMS-R-206
OMB NO: 0938-0703 EXPIRATION DATE: 08/31/2006
RESPS:3,242,500 HOURS:914,347 COSTS(000):$0
Information Collection Requirements Referenced in HIPAA, Title 1
for the Individual Market, Supporting Regulations at 45 CFR
148.120, 148.122, 148.124, 148.126, and 148.128, and Forms/....
FORMS: CMS-R-205
OMB NO: 0938-0707 EXPIRATION DATE: 05/31/2008
RESPS:40 HOURS:3,200 COSTS(000):$0
Model Application Template for State Child Health Plan Under
Title XXI of the Social Security Act, State Children's Health
Insurance Program, & Model Application Template & Instructions
FORMS: CMS-R-211
OMB NO: 0938-0709 EXPIRATION DATE: 02/28/2007
RESPS:15,000 HOURS:3,000 COSTS(000):$0
Data Collection for the Second Generation Social Health
Maintenance Organization Demonstration
FORMS: CMS-R-204
OMB NO: 0938-0714 EXPIRATION DATE: 11/30/2007
RESPS:200 HOURS:2,000 COSTS(000):$400
Procedures for advisory opinions concerning physician referrals
and supporting regulations in 42 CFR Sections 411.370 through
411.389
FORMS: CMS-R-216
OMB NO: 0938-0717 EXPIRATION DATE: 11/30/2007
RESPS:35,000 HOURS:280,000 COSTS(000):$0
Information Collection Requirements Referenced in 42 CFR Sec.
424.57; Additional DMEPOS Supplier Standards
FORMS: CMS-R-215
OMB NO: 0938-0721 EXPIRATION DATE: 08/31/2007
RESPS:500 HOURS:42 COSTS(000):$0
Independent Diagnostic Testing Facility and Supporting
Regulations Contained in 42 CFR 410.33
FORMS: CMS-R-214
OMB NO: 0938-0723 EXPIRATION DATE: 02/28/2009
RESPS:11 HOURS:2,200 COSTS(000):$0
Medicare Integrity Program Organizational Conflict of Interest
Disclosure Certificate and Supporting Regs at 42 CFR 421.300-
421.316
FORMS: CMS-R-232
OMB NO: 0938-0730 EXPIRATION DATE: 04/30/2007
RESPS:26,820 HOURS:7,197 COSTS(000):$0
Subpart D-Private Contracts and Supporting Regulations in 42 CFR
405.410, 405.430, 405.435, 405.440, 405.445, 405.455, 410.61,
415.110, and 424.24
FORMS: R-234
OMB NO: 0938-0731 EXPIRATION DATE: 06/30/2008
RESPS:448 HOURS:7,840 COSTS(000):$0
Quarterly Children's Health Insurance Program Statement of
Expenditures for Title XXI
FORMS: CMS-21
OMB NO: 0938-0732 EXPIRATION DATE: 04/30/2007
RESPS:168,000 HOURS:55,450 COSTS(000):$0
The Medicare Managed Care CAHPS Survey and Supporting
Regulations in 42 CFR 417.126 and 417.470
FORMS: CMS-R-246
OMB NO: 0938-0734 EXPIRATION DATE: 09/30/2007
RESPS:1,500 HOURS:750 COSTS(000):$0
Data Use Agreement Information Collection Requirements, Model
Language, and Supporting Regulations in 45 CFR Section 5b
FORMS: CMS-R-235
OMB NO: 0938-0738 EXPIRATION DATE: 12/31/2008
RESPS:5,700 HOURS:1,425 COSTS(000):$0
National Medical & You Education Program (NMEP) Survey of
Medicare Beneficiaries
FORMS: CMS-R-254
OMB NO: 0938-0739 EXPIRATION DATE: 05/31/2009
RESPS:4,719,118 HOURS:3,284,247 COSTS(000):$0
SNF Resident Assessment MDS Data and Supporting Regulations at
42 CFR 413.337, 413.343 and 424.32, and 483.20
FORMS: R-250
OMB NO: 0938-0741 EXPIRATION DATE: 12/31/2008
RESPS:50,000 HOURS:3,300 COSTS(000):$0
Medicare Advantage Disenrollment Form to Original Medicare
FORMS: R-257
OMB NO: 0938-0746 EXPIRATION DATE: 08/31/2008
RESPS:52 HOURS:1,976 COSTS(000):$0
Medicaid Disproportionate Share Hospital Annual Reporting
FORMS: R-266
OMB NO: 0938-0749 EXPIRATION DATE: 11/30/2007
RESPS:20,000 HOURS:10,000 COSTS(000):$0
On-Site Inspection for Durable Medical Equipment (DME) Supplier
Location and Supporting Regulations in 42 CFR, Section 424.57
FORMS: CMS-R-263
OMB NO: 0938-0753 EXPIRATION DATE: 07/31/2008
RESPS:13,121,407 HOURS:2,064,439 COSTS(000):$0
Medicare Plus Choice Program Requirements Referenced in 42 CFR
422.000 - 422.700
FORMS: CMS-R-267
OMB NO: 0938-0754 EXPIRATION DATE: 05/31/2008
RESPS:80,000 HOURS:1 COSTS(000):$0
Inpatient Psychiatric Services for Individuals Under Age 21 and
Supporting Regs.
FORMS: R-238
OMB NO: 0938-0756 EXPIRATION DATE: 03/31/2008
RESPS:7,000 HOURS:583 COSTS(000):$0
MSInteractive Survey Tool for www.medicare.gov
FORMS: CMS-R-268
OMB NO: 0938-0758 EXPIRATION DATE: 01/31/2008
RESPS:1,720 HOURS:302,720 COSTS(000):$0
Hospice Cost Report and Supporting Regulations in 42 CFR 413.20
and 413.24
FORMS: CMS-R-249
OMB NO: 0938-0760 EXPIRATION DATE: 08/31/2006
RESPS:10,156,569 HOURS:8,556,995 COSTS(000):$0
Medicare and Medicaid Programs OASIS Collection Requirements as
Part of the CoPs for HHAs and Supp. Regs. in 42 CFR 484.55,
484.205, 484.245, 484.250
FORMS: R-245
OMB NO: 0938-0761 EXPIRATION DATE: 06/30/2009
RESPS:102,203 HOURS:1,374,051 COSTS(000):$20
Medicare and Medicaid Programs: Use and Reporting of OASIS Data
as Part of the CoPs for HHAs and Supporting Regulations in 42
CFR 484.11 and 484.20
FORMS: R-209
OMB NO: 0938-0763 EXPIRATION DATE: 08/31/2006
RESPS:5,807 HOURS:13,272 COSTS(000):$0
The Plan Benefit Package (PBP) and Formulary Submission for
Medicare Advantage (MA) Plans and Prescription Drug Plans (PDPs)
FORMS: CMS-R-262
OMB NO: 0938-0769 EXPIRATION DATE: 03/31/2009
RESPS:1,500 HOURS:375 COSTS(000):$0
Request for Retirement Benefit Informatin (BBA '97)
FORMS: CMS-R-285
OMB NO: 0938-0770 EXPIRATION DATE: 09/30/2008
RESPS:4,731 HOURS:20,372 COSTS(000):$0
Community Mental Health Center Site Visit Assessment Tool and
Supporting Regulations in 42 CFR 410.2
FORMS: CMS-R-273
OMB NO: 0938-0776 EXPIRATION DATE: 09/30/2007
RESPS:200 HOURS:8,000 COSTS(000):$0
Medicare Program: Process for Making National Coverage
Determinations
FORMS: CMS-R-0290
OMB NO: 0938-0777 EXPIRATION DATE: 08/31/2006
RESPS:17,996 HOURS:2,999 COSTS(000):$0
Medicare Lifestyle Modification Program Demonstration and
Addendum
FORMS: CMS-R-289
OMB NO: 0938-0778 EXPIRATION DATE: 01/31/2007
RESPS:616 HOURS:438 COSTS(000):$0
Medicare + Choice Organization Appeals and Grievance Data
Collection and Reporting Requirements. Data Disclosure
Requirements 422.111 and 422.564
FORMS: CMS-R-0282
OMB NO: 0938-0779 EXPIRATION DATE: 09/30/2008
RESPS:44,200 HOURS:18,564 COSTS(000):$0
Medicare CAHPS Disenrollment Surveys and Supporting Regs. in 42
CFR 417.126, 417.470, 422.64, and 422.210
FORMS: CMS-R-295
OMB NO: 0938-0781 EXPIRATION DATE: 08/31/2006
RESPS:31,000 HOURS:3,100 COSTS(000):$0
Home Health Advance Beneficiary Notices and Supporting
Regulations in 42 CFR, Section 411.404 and 484.10(a) and (e)
FORMS: CMS-R-296
OMB NO: 0938-0786 EXPIRATION DATE: 06/30/2009
RESPS:14,226 HOURS:648,877 COSTS(000):$0
External Quality Review of Medicaid MCOs and Supporting
Regulations in 42 CFR 438.360, 438.362, and 438.364
FORMS: CMS-R-0305
OMB NO: 0938-0787 EXPIRATION DATE: 09/30/2007
RESPS:5,000 HOURS:1,250 COSTS(000):$0
Request for Employment Information
FORMS: CMS-R-297
OMB NO: 0938-0790 EXPIRATION DATE: 02/28/2009
RESPS:54 HOURS:44,378 COSTS(000):$0
Medicare and Medicaid; Programs For All-Inclusive Care For The
Elderly (PACE) Contained in 42 CFR 460.12-460.210
FORMS: R-244
OMB NO: 0938-0791 EXPIRATION DATE: 05/31/2007
RESPS:116,038 HOURS:16,960 COSTS(000):$0
A Project to Develop an Outcome-ased Continuous Quality
Improvement System and Core Outcome and Comprehensive Assessment
Data Set for PACE
FORMS: CMS-R-299
OMB NO: 0938-0792 EXPIRATION DATE: 01/31/2007
RESPS:3,528 HOURS:3,435 COSTS(000):$0
Refinement of RHC Certification and QAPI and Supporting
Regulations in 42 CFR 491.8 and 491.11
FORMS: CMS-R-0242
OMB NO: 0938-0795 EXPIRATION DATE: 09/30/2007
RESPS:37 HOURS:11,100 COSTS(000):$0
Conflict of Interest and Ownership and Control Informaiton
FORMS: CMS-R-312
OMB NO: 0938-0796 EXPIRATION DATE: 04/30/2007
RESPS:142,920 HOURS:47,640 COSTS(000):$0
Medicare Consumer Assessment of Health Plan Survey-Fee For
Service (CAHPS-FFS)
FORMS: CMS-10000
OMB NO: 0938-0798 EXPIRATION DATE: 11/30/2006
RESPS:2,272 HOURS:41,063 COSTS(000):$0
Prospective Payments for Hospital Outpatient Services and
Supporting Regulations in 42 CFR 413.24, 413.65, and 419.42
FORMS: CMS-R-240
OMB NO: 0938-0802 EXPIRATION DATE: 06/30/2008
RESPS:58 HOURS:203 COSTS(000):$0
Eligibility of Drugs, Biologicals and Radio-pharmaceuticals for
Pass-Through Provisions Under the OPPS Supporting Regulations in
42 CFR Part 419.43
FORMS: 10008
OMB NO: 0938-0806 EXPIRATION DATE: 07/31/2008
RESPS:7,094 HOURS:12,379 COSTS(000):$0
Informatics, Telemedicine, and Education Demonstration Project
FORMS: CMS-10014
OMB NO: 0938-0812 EXPIRATION DATE: 11/30/2006
RESPS:2,000 HOURS:500 COSTS(000):$0
Employee Building Pass Application and File
FORMS: CMS-730 CMS-80
OMB NO: 0938-0818 EXPIRATION DATE: 01/31/2007
RESPS:6,832 HOURS:75,294 COSTS(000):$0
Expanded Coverage for Diabetes Outpatient Self-Management
Training Services and Supporting Regulations Contained in 42 CFR
410.141, 410.142, 410.143, 410.144, 410.145, 410.146....
FORMS: R-247
OMB NO: 0938-0819 EXPIRATION DATE: 04/30/2009
RESPS:2,600 HOURS:100 COSTS(000):$0
HIPAA Nondiscrimination Provisions (Regulation HCFA-2078-P)
FORMS: CMS-10009
OMB NO: 0938-0827 EXPIRATION DATE: 04/30/2009
RESPS:18 HOURS:194 COSTS(000):$0
HIPAA Nondiscrimination Provisions (Regulation HCFA-2022-IFC)
FORMS: CMS-10001
OMB NO: 0938-0829 EXPIRATION DATE: 05/31/2007
RESPS:71,200 HOURS:7,120 COSTS(000):$0
Medicare+Choice Appeal Notices, "Notice of Denial of Medical
Coverage", "Notice of Denial of Payment" and supporting
regulations in 42 CFR 422.568
FORMS: CMS-10003
OMB NO: 0938-0832 EXPIRATION DATE: 09/30/2007
RESPS:3,300 HOURS:275 COSTS(000):$0
Health Insurance Benefit Agreement and Supporting Regulations at
42 CFR Part 489 and 491
FORMS: CMS-1561 CMS-1561A
OMB NO: 0938-0833 EXPIRATION DATE: 05/31/2008
RESPS:1,199,000 HOURS:713,250 COSTS(000):$0
Restraint and Seclusion Standards for Psychiatric Residential
Treatment Facilities
FORMS: CMS-R-306
OMB NO: 0938-0841 EXPIRATION DATE: 08/31/2007
RESPS:1,114,124 HOURS:864,973 COSTS(000):$0
State Children's Health Insurance Program and Supporting
Regulations in 42 CFR 431.636, 457.50, 457.60, 457.70, 457.340,
457.350, 457.431, 457.440, 457.525, 457.560,...
FORMS: CMS-R-308
OMB NO: 0938-0842 EXPIRATION DATE: 03/31/2009
RESPS:390,000 HOURS:421,939 COSTS(000):$0
Inpatient Rehabilitation Assessment Instrument and Data Set for
PPS for Inpatient Rehabilitation Facilities
FORMS: 10036
OMB NO: 0938-0846 EXPIRATION DATE: 11/30/2007
RESPS:62,824 HOURS:422,008 COSTS(000):$0
Physicians' Referrals to Health Care Entitles With Which They
Have Financial Relationships and Supporting Regulations in 42
CFR, Sections 411.352 through 411.361
FORMS: CMS-10047
OMB NO: 0938-0850 EXPIRATION DATE: 02/28/2007
RESPS:1,000,000 HOURS:116,747 COSTS(000):$0
State Health Insurance Assistance Program (SHIP) Client Contact
Form, Public and Media Activity Form, and Resource Report
FORMS: CMS-10028A B C
OMB NO: 0938-0857 EXPIRATION DATE: 01/31/2008
RESPS:12 HOURS:192 COSTS(000):$0
Recognition of pass-through payment for additional (new)
categories of devices under the Outpatient Prospective Payment
System and Supporting Regulations in 42 CFR, Part 419
FORMS: CMS-10052
OMB NO: 0938-0860 EXPIRATION DATE: 03/31/2008
RESPS:15 HOURS:180 COSTS(000):$0
Recognition of Payment for New Technology Services for
Ambulatory Payment Classifications (APCs) under the Outpatient
Propsective Payment System and Supporting....
FORMS: CMS-10054
OMB NO: 0938-0866 EXPIRATION DATE: 02/29/2008
RESPS:3,400,000 HOURS:1 COSTS(000):$0
ICRs Contained in 45 CFR Part 162; HIPAA Standards for
Electronic Transactions
FORMS: CMS-R-218
OMB NO: 0938-0869 EXPIRATION DATE: 08/31/2006
RESPS:3,600 HOURS:1,080 COSTS(000):$0
Survey of Newly Eligible Medicare Beneficiaries
FORMS: CMS-10050
OMB NO: 0938-0871 EXPIRATION DATE: 04/30/2009
RESPS:1,680 HOURS:1,106 COSTS(000):$0
Medicare Lifestyle Modification Program Demonstration
FORMS: CMS-10044
OMB NO: 0938-0872 EXPIRATION DATE: 11/30/2008
RESPS:92,789 HOURS:51,314 COSTS(000):$100
Minimum Data Set (MDS) For Swing Bed Hospitals and Supporting
Regulations in 42 CFR 483.20 and 413.337
FORMS: 10064
OMB NO: 0938-0873 EXPIRATION DATE: 09/30/2008
RESPS:250 HOURS:620 COSTS(000):$0
Quality Assessment and Performance Improvement (QAPI) Project
Completion Report 42 CFR 422.152
FORMS: CMS-10060
OMB NO: 0938-0874 EXPIRATION DATE: 10/31/2008
RESPS:2,550,000 HOURS:1 COSTS(000):$0
HIPAA Standard Unique Employer Identifier and Supporting
Regulations in 45 CFR Part 160 and 162
FORMS: CMS-R-220
OMB NO: 0938-0878 EXPIRATION DATE: 04/30/2009
RESPS:14,091,370 HOURS:8,351 COSTS(000):$0
Collection of Diagnostic Data from Medicare Advantage
Organizations for Risk Adjusted Payments Supporting Reg 42 CFR
Part 422 & 423 Subparts F and G
FORMS: CMS-10062
OMB NO: 0938-0880 EXPIRATION DATE: 08/31/2006
RESPS:800 HOURS:133 COSTS(000):$0
Medicare Waiver Demonstration Application
FORMS: CMS-10069
OMB NO: 0938-0887 EXPIRATION DATE: 10/31/2006
RESPS:20 HOURS:840 COSTS(000):$0
Matching Gants to States for the Operation of High Risk Pools
and Supporting Regulations at 42 CFR 148.316, 148.318, and
148.320
FORMS: CMS-10078
OMB NO: 0938-0889 EXPIRATION DATE: 09/30/2006
RESPS:25 HOURS:115 COSTS(000):$0
Pharmacy Plus Template Application
FORMS: CMS-10067
OMB NO: 0938-0890 EXPIRATION DATE: 03/31/2007
RESPS:4,500 HOURS:1,078 COSTS(000):$0
Design and Implementation of a Targeted Beneficiary Survey on
Access to Physician Services Among Medicare Beneficiaries
FORMS: CMS-10084
OMB NO: 0938-0892 EXPIRATION DATE: 08/31/2006
RESPS:3,000 HOURS:850 COSTS(000):$0
Publications Use Study
FORMS: CMS-10080
OMB NO: 0938-0893 EXPIRATION DATE: 09/30/2006
RESPS:928 HOURS:253 COSTS(000):$0
Data Collection for Administering the Survey for the Evaluation
of the Demonstration to Maintain Independence and Employment
(DMIE)
FORMS: CMS-10081
OMB NO: 0938-0894 EXPIRATION DATE: 03/31/2008
RESPS:5,089 HOURS:509 COSTS(000):$0
Assessing the Division of Beneficiary Inquiry Service's
Performance for Written Responses
FORMS: CMS-10068
OMB NO: 0938-0897 EXPIRATION DATE: 10/31/2006
RESPS:194 HOURS:49 COSTS(000):$0
Election to be paid 100% of PPS rates rather than 5-year
phase-in and Notification of FIs and CMS of co-located Medicare
providers and Supporting Regulations in 42 CFR, Sections 412.22
and 412.533
FORMS: CMS-10088
OMB NO: 0938-0898 EXPIRATION DATE: 11/30/2007
RESPS:51 HOURS:2,360 COSTS(000):$41
CMSO Survey of States: Performance Measurement Reporting
Capability
FORMS: CMS-10082
OMB NO: 0938-0900 EXPIRATION DATE: 09/30/2007
RESPS:7,000 HOURS:583 COSTS(000):$0
MSInteractive Survey Tool for cms.hhs.gov website
FORMS: CMS-10072
OMB NO: 0938-0902 EXPIRATION DATE: 09/30/2006
RESPS:2,200 HOURS:550 COSTS(000):$0
Evaluation of the Illinois and Wisconsin State Pharmacy
Assistance Waivers
FORMS: CMS-10087
OMB NO: 0938-0903 EXPIRATION DATE: 02/28/2007
RESPS:48 HOURS:960 COSTS(000):$0
CMS/AoA Aging and Disability Resource Center Grant Program (Real
Choice Systems Change Grants for Community Living and the Older
Americans Act, Public Law 106-501 (Catalog of Federal Domestic...
FORMS: CMS-10093
OMB NO: 0938-0905 EXPIRATION DATE: 03/31/2007
RESPS:10,980 HOURS:915 COSTS(000):$0
Accepting New Patients Indicator UPIN (Unique Physician
Identifi- cation Number) Participating Physicians Directory
FORMS: CMS-10091
OMB NO: 0938-0906 EXPIRATION DATE: 02/28/2007
RESPS:11,310 HOURS:1,087 COSTS(000):$0
Evaluation of the Medicaid Health Reform Demonstrations
FORMS: CMS-10094
OMB NO: 0938-0907 EXPIRATION DATE: 05/31/2009
RESPS:3,800 HOURS:1,216,000 COSTS(000):$0
Hospital Wage Index Occupational Mix Survey and Supporting
Regulations in 42 CFR Sections 412.230, 412.304 and 413.65
FORMS: 10079
OMB NO: 0938-0910 EXPIRATION DATE: 03/31/2007
RESPS:612,000 HOURS:68,000 COSTS(000):$0
"Detailed Explanation of Non-Coverage" and "Important Medicare
Message of Non-Coverage" and Supporting Regulations in 42 CFR
422.620, 422.624, and 422.626
FORMS: CMS-10095
OMB NO: 0938-0911 EXPIRATION DATE: 03/31/2007
RESPS:1,040 HOURS:4,160 COSTS(000):$0
Review of National Coverage Determinations and Local Coverage
Determinations and Supporting Regulations in 42 CFR, Sections
426.400 and 426.500
FORMS: CMS-10099
OMB NO: 0938-0912 EXPIRATION DATE: 02/28/2007
RESPS:40,000 HOURS:6,667 COSTS(000):$0
Medicare Health Survey (MHS)
FORMS: CMS-10096
OMB NO: 0938-0915 EXPIRATION DATE: 06/30/2009
RESPS:20,514 HOURS:6,923 COSTS(000):$0
Medicare Contractor Provider Satisfaction Survey (MCPSS) and
Supporting Regulations in 42 CFR 421.120 and 421.122
FORMS: CMS-10097
OMB NO: 0938-0916 EXPIRATION DATE: 03/31/2007
RESPS:3,400 HOURS:20,400 COSTS(000):$0
Paid Feeding Assistants in Long Term Care Facilities and
Supporting Regulations Contained in 42 CFR 483.160
FORMS: NONE
OMB NO: 0938-0917 EXPIRATION DATE: 02/28/2007
RESPS:38,216 HOURS:9,556 COSTS(000):$0
Survey of Medicare Preferred Provider Organization Demonstration
FORMS: CMS-10101
OMB NO: 0938-0918 EXPIRATION DATE: 12/31/2008
RESPS:16,000 HOURS:238,000 COSTS(000):$0
National Voluntary Hospital Reporting Initiative--Hospital
Quality Measures
FORMS: CMS-10109
OMB NO: 0938-0919 EXPIRATION DATE: 03/31/2007
RESPS:14,400 HOURS:1,800 COSTS(000):$0
1-800-MEDICARE Beneficiary Satisfaction Survey
FORMS: CMS-10098
OMB NO: 0938-0920 EXPIRATION DATE: 04/30/2007
RESPS:42,101,275 HOURS:3,917,643 COSTS(000):$0
Medicaid Managed Care and Supporting Regulations in 42 CFR
438.6, 438.8, 438.10, 438.12, 138.50, 438.56, 438.102, 438.114,
438.202, 438.206, 438.207, 438.240, 438.242, 438.402, 438.404,
438.406...
FORMS: CMS-10108
OMB NO: 0938-0921 EXPIRATION DATE: 05/31/2009
RESPS:480 HOURS:17,760 COSTS(000):$0
Manufacturer Submission of Average Sales Price (ASP) Data for
Medicare Part B Drugs and Biological and Supporting Regulations
FORMS: CMS-10110
OMB NO: 0938-0922 EXPIRATION DATE: 01/31/2008
RESPS:1,120 HOURS:2,464 COSTS(000):$0
Instrument/tool for refinement of a prospective payment system
for patients in inpatient psychiatric hospitals, and units: a
pilot test
FORMS: CMS-10107
OMB NO: 0938-0924 EXPIRATION DATE: 01/31/2008
RESPS:50,000 HOURS:20,417 COSTS(000):$0
Application for Participation in Medicare Replacement Drug
Demonstration
FORMS: CMS-10113
OMB NO: 0938-0926 EXPIRATION DATE: 12/31/2007
RESPS:3,000 HOURS:1,500 COSTS(000):$0
In-Center Hemodialysis CAHPS Survey
FORMS: CMS-10105
OMB NO: 0938-0929 EXPIRATION DATE: 05/31/2008
RESPS:62,500 HOURS:31,250 COSTS(000):$0
Federal Funding of Emergency Health Services (Section 1011):
Enrollment Application
FORMS: 10115
OMB NO: 0938-0930 EXPIRATION DATE: 11/30/2007
RESPS:1,000,000 HOURS:250,000 COSTS(000):$0
Medicare Authorization to Disclose Personal Health Information
FORMS: CMS-10106
OMB NO: 0938-0931 EXPIRATION DATE: 02/29/2008
RESPS:1,193,945 HOURS:448,128 COSTS(000):$0
National Provider Identifier (NPI) Application and Update Form
and Supporting Regs in 45 CFR 142.408, 45 CFR 162.408, 45 CFR
162.406
FORMS: CMS-10114
OMB NO: 0938-0932 EXPIRATION DATE: 01/31/2008
RESPS:2,753 HOURS:1,330 COSTS(000):$0
Evaluation of PACE as a Permanent Program and a For Profit
Demonstration
FORMS: CMS-10103
OMB NO: 0938-0933 EXPIRATION DATE: 01/31/2008
RESPS:10 HOURS:100 COSTS(000):$0
1932 State Plan Amendment Template, State Plan Requirements, and
Supporting Regulations in 42 CFR 438.50
FORMS: CMS-10120
OMB NO: 0938-0935 EXPIRATION DATE: 10/31/2006
RESPS:90 HOURS:2,770 COSTS(000):$0
Medicare Advantage Applications
FORMS: CMS-10117 CMS-10118 CMS-10119 CMS-10135 CMS-10136
OMB NO: 0938-0936 EXPIRATION DATE: 08/31/2006
RESPS:101 HOURS:3,828 COSTS(000):$0
Applications for Medicare Part D plans: PDP Plans, MA-PD Plans,
Cost Plans, PACE organizations, SAE and EPOG
FORMS: CMS-10137
OMB NO: 0938-0938 EXPIRATION DATE: 04/30/2008
RESPS:1,600 HOURS:792 COSTS(000):$0
Public Reporting on Quality Outcomes National Survey of Hospital
Executives ("PRO QUO")
FORMS: CMS-10128
OMB NO: 0938-0939 EXPIRATION DATE: 06/30/2008
RESPS:2,000 HOURS:16,000 COSTS(000):$0
Phone Surveys of Product/Service for Medicare Payment Validation
and Supporting Regulations in 42 CFR, 405.502
FORMS: CMS-10112
OMB NO: 0938-0941 EXPIRATION DATE: 12/31/2008
RESPS:800 HOURS:19,200 COSTS(000):$0
Medicare Care Management Performance Demonstration (MCMP)
Standardized Ambulatory Care Quality Measure Collection
Initiative
FORMS: 10136
OMB NO: 0938-0942 EXPIRATION DATE: 01/31/2009
RESPS:10 HOURS:790 COSTS(000):$0
Physician Group Practice (PGP) Standardized Ambulatory Care
Quality Measure Collection Initiative
FORMS: CMS-10134
OMB NO: 0938-0943 EXPIRATION DATE: 05/31/2008
RESPS:2,500 HOURS:1,625 COSTS(000):$0
Evaluation of Medicare Disease Management Demonstrations
FORMS: CMS-10131
OMB NO: 0938-0944 EXPIRATION DATE: 03/31/2009
RESPS:4,830 HOURS:36,190 COSTS(000):$0
Bid Pricing Tool (BPT) for Medicare Advantage (MA) Plans and
Prescription Drug Plans (PDP)
FORMS: CMS-10142
OMB NO: 0938-0948 EXPIRATION DATE: 12/31/2008
RESPS:500 HOURS:500 COSTS(000):$0
HIPAA Administrative Simplification Non-Privacy Enforcement
FORMS: CMS-10148
OMB NO: 0938-0949 EXPIRATION DATE: 03/31/2009
RESPS:4,000,000 HOURS:64,539,263 COSTS(000):$0
Health Insurance Reform Security Standards - Final Rule
FORMS: CMS-10149
OMB NO: 0938-0950 EXPIRATION DATE: 07/31/2008
RESPS:5,455,461 HOURS:6,819 COSTS(000):$0
Appointment of Representative and Supporting Regulations in 42
CFR 405.910
FORMS: CMS-1696
OMB NO: 0938-0951 EXPIRATION DATE: 12/31/2008
RESPS:18,200 HOURS:36,400 COSTS(000):$0
Collection of Drug Pricing and Network Pharmacy Data from
Medicare Prescription Drug Plans (PDP and MA-PD) and Supporting
Regulations in 42 CFR 423.48
FORMS: CMS-10150
OMB NO: 0938-0952 EXPIRATION DATE: 01/31/2009
RESPS:7,512,000 HOURS:634,000 COSTS(000):$0
Federal Funding of Emergency Health Services (Section 1011);
Provider Payment Determination and On-Call Cost Forms
FORMS: CMS-10130
OMB NO: 0938-0953 EXPIRATION DATE: 06/30/2008
RESPS:4,292,400 HOURS:379,400 COSTS(000):$0
Expedited Review Notices and Supporting Regulations Contained in
42 CFR SEction 405.1200 and 405.1202
FORMS: CMS-10123 CMS-10124
OMB NO: 0938-0954 EXPIRATION DATE: 07/31/2008
RESPS:10 HOURS:80 COSTS(000):$0
Medicare Part B Drug and Biological CAP and Supporting
Regulations in 42 CFR Sections 414.906, 414.908, 414.910,
414.914 and 414.916
FORMS: CMS-10145
OMB NO: 0938-0955 EXPIRATION DATE: 08/31/2006
RESPS:12 HOURS:480 COSTS(000):$0
Medicare Part B Drug and Biological Competitive Acquisition
Program Applications
FORMS: CMS-10133
OMB NO: 0938-0957 EXPIRATION DATE: 02/28/2009
RESPS:50,000 HOURS:2,025,000 COSTS(000):$0
Retiree Drug Subsidy (RDS) Application and Instructions
FORMS: CMS-10156
OMB NO: 0938-0958 EXPIRATION DATE: 08/31/2008
RESPS:612 HOURS:10,710 COSTS(000):$0
Monthly State File of Medicaid/Medicare Dual Eligible Enrollees
FORMS: CMS-10143
OMB NO: 0938-0960 EXPIRATION DATE: 03/31/2009
RESPS:122,000 HOURS:45,000 COSTS(000):$0
CMS Real-Time Eligibility Agreement and MDCN Access Request
FORMS: CMS-10157
OMB NO: 0938-0963 EXPIRATION DATE: 03/31/2009
RESPS:31,200 HOURS:4,940 COSTS(000):$0
1-800-MEDICARE Customer Experience Questionnaire
FORMS: CMS-10163
OMB NO: 0938-0964 EXPIRATION DATE: 08/31/2008
RESPS:35,439,719 HOURS:212,044,545 COSTS(000):$0
Medicare Prescription Drug Benefit Program
FORMS: CMS-10141
OMB NO: 0938-0965 EXPIRATION DATE: 03/31/2009
RESPS:800 HOURS:133 COSTS(000):$0
Application for Participation in Medicare Care Management
Performance Demonstration
FORMS: CMS-10165
OMB NO: 0938-0967 EXPIRATION DATE: 11/30/2008
RESPS:50,000 HOURS:4,167 COSTS(000):$0
Data Collection for Medicare Beneficiaries Receiving Implantable
Cardioverter-defibrillators for Primary Prevention of Sudden
Cardiac Death
FORMS: CMS-10151
OMB NO: 0938-0968 EXPIRATION DATE: 11/30/2008
RESPS:50,000 HOURS:4,167 COSTS(000):$0
Collection for Medicare Bene#s Receiving FDG Positron Emissions
Tomography for Brain, Cervical, Ovarian, Small Cell Lung, and
Testicular Cancers
FORMS: CMS-10152
OMB NO: 0938-0969 EXPIRATION DATE: 08/31/2006
RESPS:2,900,000 HOURS:483,333 COSTS(000):$0
Medicare Program: Complex Medical Review
FORMS: CMS-10168
OMB NO: 0938-0971 EXPIRATION DATE: 08/31/2006
RESPS:37,400 HOURS:37,400 COSTS(000):$0
Medicare Program: Conditions of Payment of Power Mobility
Devices, Including Power Wheelchairs and Power-Operated Vehicles
(CMS-3017-IFC)
FORMS: CMS-10116
OMB NO: 0938-0972 EXPIRATION DATE: 12/31/2008
RESPS:1,580 HOURS:395 COSTS(000):$0
Consumer Assessment of Health Behaviors Survey
FORMS: CMS-10160
OMB NO: 0938-0973 EXPIRATION DATE: 12/31/2008
RESPS:1,730 HOURS:346 COSTS(000):$0
Physician Assessment of Hospital Quality Reports
FORMS: CMS-10154
OMB NO: 0938-0974 EXPIRATION DATE: 10/31/2008
RESPS:58,680 HOURS:58,680 COSTS(000):$0
Payment Error Rate Measurement in Medicaid and the State
Children Health Insurance Program
FORMS: CMS-10166
OMB NO: 0938-0975 EXPIRATION DATE: 11/30/2008
RESPS:35,000,000 HOURS:583,333 COSTS(000):$0
Medicare Prescription Drug Coverage and Your Rights
FORMS: CMS-10147 CMS-10147-SP
OMB NO: 0938-0976 EXPIRATION DATE: 11/30/2008
RESPS:1,056,000 HOURS:528,000 COSTS(000):$53
Notice of Denial of Medicare Prescription Drug Coverage
FORMS: CMS-10146 CMS-10146-SP
OMB NO: 0938-0977 EXPIRATION DATE: 05/31/2009
RESPS:6,000 HOURS:222,000 COSTS(000):$68,136
Retiree Drug Subsidy Payment Request Instructions
FORMS: CMS-10170
OMB NO: 0938-0978 EXPIRATION DATE: 06/30/2009
RESPS:2,153,767,270 HOURS:1,017,914 COSTS(000):$0
Coordination of Benefits between Part D Plans and Other
Prescription Coverage Providers
FORMS: CMS-10171
OMB NO: 0938-0979 EXPIRATION DATE: 01/31/2009
RESPS:836 HOURS:6,440 COSTS(000):$0
New Freedom Initiative - Web-based Reporting System for Grantees
FORMS: CMS-10161
OMB NO: 0938-0980 EXPIRATION DATE: 12/31/2008
RESPS:9,449 HOURS:2,363 COSTS(000):$0
Medicare Care Improvement Survey
FORMS: CMS-10162
OMB NO: 0938-0981 EXPIRATION DATE: 12/31/2007
RESPS:2,852,000 HOURS:285,200 COSTS(000):$0
National Implementation of Hospital Consumer Assessment of
Health Providers and Systems (HCAHPS)
FORMS: CMS-10102
OMB NO: 0938-0982 EXPIRATION DATE: 08/31/2006
RESPS:2,418,000,000 HOURS:4,836 COSTS(000):$0
Collection of Prescription Drug Data from MA-PD, PDP and Fallout
Plans/Sponsors for Medicare Part D Payments
FORMS: CMS-10174
OMB NO: 0938-0983 EXPIRATION DATE: 02/28/2009
RESPS:1,220,000 HOURS:400,000 COSTS(000):$0
Medicare EDI Enrollment Form and EDI Registration
FORMS: CMS-10164
OMB NO: 0938-0984 EXPIRATION DATE: 08/31/2006
RESPS:1,000 HOURS:3,000 COSTS(000):$0
Certification Statement for Electronic File Interchange
Organizations that submit NPI Data to the National Plan and
Provider Enumeration System
FORMS: CMS-10175
OMB NO: 0938-0985 EXPIRATION DATE: 03/31/2009
RESPS:26,643 HOURS:12,416 COSTS(000):$0
Medicare Health Support Program Medical Records Abstraction
FORMS: CMS-10172
OMB NO: 0938-0986 EXPIRATION DATE: 03/31/2009
RESPS:1,227 HOURS:307 COSTS(000):$0
Rehabilitation Unit Criteria Work Sheet and Rehabilitation
Hospital Criteria Work Sheet and Supporting Regulations at 42
CFR 412.20-412.30
FORMS: CMS-437A CMS-437B
OMB NO: 0938-0987 EXPIRATION DATE: 04/30/2009
RESPS:10,000 HOURS:20,000 COSTS(000):$0
Competitive Acquisition Program (CAP) for Medicare Part B Drugs:
CAP Physician Election Agreement
FORMS: CMS-10167
OMB NO: 0938-0988 EXPIRATION DATE: 09/30/2006
RESPS:56 HOURS:336 COSTS(000):$0
State Children's Health Insurance Program (SCHIP) Report on
Payables and Receivables
FORMS: CMS-10180
OMB NO: 0938-0989 EXPIRATION DATE: 06/30/2007
RESPS:60,000,000 HOURS:15,000,000 COSTS(000):$0
Individuals Authorized Access to the CMS Computer Services
FORMS: CMS-10173
OMB NO: 0938-0990 EXPIRATION DATE: 09/30/2006
RESPS:1,225,173 HOURS:522,204 COSTS(000):$0
Model Creditable Coverage Disclosure Notices
FORMS: CMS-10182
OMB NO: 0938-0992 EXPIRATION DATE: 09/30/2006
RESPS:12,812 HOURS:102,496 COSTS(000):$0
Medicare Part D Reporting Requirements
FORMS: CMS-10185
OMB NO: 0938-0993 EXPIRATION DATE: 09/30/2006
RESPS:56 HOURS:56 COSTS(000):$0
State Plan Preprints to Implement Sections of the Deficit
Reduction Act of 2006
FORMS: CMS-10190
OMB NO: 0938-0995 EXPIRATION DATE: 08/31/2006
RESPS:450 HOURS:1,800 COSTS(000):$0
Strategic and Implementing Plan Regarding Specialty Hospitals -
Section 5006 of the DRA
FORMS: CMS-10092
OMB NO: 0938-0999 EXPIRATION DATE: 06/30/2007
RESPS:957,204,707 HOURS:46,383,364 COSTS(000):$0
Insurance Common Claims Form and Supporting Regulations at 42
CFR Part 424 Subpart C
FORMS: CMS-1500(08-05) CMS-1490S
SUBAGENCY TOTALS
ACTIVE ANNUAL ANNUAL ANNUAL
REPORTS RESPONSES HOURS COSTS($000)
257 7,433,173,028 478,942,781 $69,179
Administration for Children and Families
OMB NO: 0970-0004 EXPIRATION DATE: 11/30/2008
RESPS:52 HOURS:13,746 COSTS(000):$0
Annual Statistical Report on Children in Foster Homes and in
Families Receiving Payments in Excess of the Poverty Income
Level from a State Program
FORMS: ACF-4125
OMB NO: 0970-0017 EXPIRATION DATE: 11/30/2007
RESPS:324 HOURS:243 COSTS(000):$0
State Plan for Child Support Collection and Establishment of
Paternity Under Title IV-D of the Social Security Act
FORMS: OCSE-100 OCSE-21-U4
OMB NO: 0970-0030 EXPIRATION DATE: 02/29/2008
RESPS:1 HOURS:24 COSTS(000):$384
Refugee Resettlement Program Estimates: CMA
FORMS: ORR-1
OMB NO: 0970-0033 EXPIRATION DATE: 05/31/2007
RESPS:1,146 HOURS:669 COSTS(000):$0
Annual Survey of Refugees
FORMS: ORR-9
OMB NO: 0970-0034 EXPIRATION DATE: 09/30/2006
RESPS:900 HOURS:255 COSTS(000):$0
ORR-3 Refugee and Entrant Unaccompanied Minor Placement Report
ORR-4 Refugee and Entrant Unaccompanied Minor Placement Report
FORMS: ORR-3 ORR-4
OMB NO: 0970-0036 EXPIRATION DATE: 05/31/2007
RESPS:4 HOURS:744 COSTS(000):$27
Quarterly Performance Report
FORMS: ORR-6
OMB NO: 0970-0037 EXPIRATION DATE: 07/31/2008
RESPS:55 HOURS:14 COSTS(000):$0
LIHEAP Quarterly Allocation Estimates
FORMS: ACF-535
OMB NO: 0970-0043 EXPIRATION DATE: 06/30/2009
RESPS:50 HOURS:425 COSTS(000):$0
Refugee State of Origin Report
FORMS: ORR-11
OMB NO: 0970-0060 EXPIRATION DATE: 10/31/2006
RESPS:184 HOURS:2,108 COSTS(000):$0
Low Income Home Energy Assistance Program (LIHEAP) Household
Report
FORMS: NONE
OMB NO: 0970-0075 EXPIRATION DATE: 10/31/2008
RESPS:180 HOURS:103 COSTS(000):$0
Application Requirements for the Low Income Home Energy
Assistance Program (LIHEAP) Model Plan
FORMS: NONE
OMB NO: 0970-0076 EXPIRATION DATE: 01/31/2008
RESPS:51 HOURS:173 COSTS(000):$0
Low Income Home Energy Assistance Program (LIHEAP) Grantee Survey
FORMS: ACF-284
OMB NO: 0970-0085 EXPIRATION DATE: 01/31/2008
RESPS:54 HOURS:662,138 COSTS(000):$0
Provision of Services in Interstate Child Support Enforcement:
Standard Forms
FORMS: NONE
OMB NO: 0970-0106 EXPIRATION DATE: 04/30/2008
RESPS:177 HOURS:531 COSTS(000):$0
Low Income Home Energy Assistance Program (LIHEAP) Carryout and
Reallotment Report
FORMS: NONE
OMB NO: 0970-0114 EXPIRATION DATE: 06/30/2008
RESPS:28 HOURS:4,552 COSTS(000):$0
Child Care and Development Fund Plan for States/Territories for
FY 2006-2007
FORMS: ACF-118
OMB NO: 0970-0121 EXPIRATION DATE: 10/31/2006
RESPS:70 HOURS:2,660 COSTS(000):$0
Low Income Home Energy Assistance (LIHEAP) Leveraging Report
FORMS: NONE
OMB NO: 0970-0123 EXPIRATION DATE: 09/30/2007
RESPS:1,070 HOURS:58,557 COSTS(000):$512
National Extranet Optimized Runaway and Homeless Youth
Management Information System (NEORHYMIS)
FORMS: NONE
OMB NO: 0970-0139 EXPIRATION DATE: 04/30/2007
RESPS:11,960 HOURS:472,400 COSTS(000):$0
ACF Uniform Project Description (UPD)
FORMS: NONE
OMB NO: 0970-0145 EXPIRATION DATE: 09/30/2008
RESPS:54 HOURS:891 COSTS(000):$0
Temporary Assistance for Needy Families (TANF) State Plan
Guidance
FORMS: NONE
OMB NO: 0970-0148 EXPIRATION DATE: 11/30/2006
RESPS:2,590 HOURS:1,737,618 COSTS(000):$0
42 C.F.R. 1304 Head Start Program Performance Standards
FORMS: NONE
OMB NO: 0970-0150 EXPIRATION DATE: 08/31/2006
RESPS:56 HOURS:2,240 COSTS(000):$280
Child Care and Development Fund Annual Aggregate Report
FORMS: ACF-800
OMB NO: 0970-0151 EXPIRATION DATE: 06/30/2009
RESPS:8,668 HOURS:6,861 COSTS(000):$0
Head Start Family and Child Experience Survey (FACES 2006)
FORMS: NONE
OMB NO: 0970-0152 EXPIRATION DATE: 01/31/2008
RESPS:1 HOURS:9,890 COSTS(000):$0
Administrative Subpoena
FORMS: NONE
OMB NO: 0970-0153 EXPIRATION DATE: 01/31/2008
RESPS:1 HOURS:27,346 COSTS(000):$0
Notice of Lien
FORMS: NONE
OMB NO: 0970-0154 EXPIRATION DATE: 05/31/2007
RESPS:216,000 HOURS:980,230 COSTS(000):$0
Order to Withhold Income for Child Support and Notice of an
Order to Withhold Income for Child Support
FORMS: NONE
OMB NO: 0970-0155 EXPIRATION DATE: 06/30/2008
RESPS:52 HOURS:3,328 COSTS(000):$0
Community-Based Family Resource and Support Grants
FORMS: NONE
OMB NO: 0970-0157 EXPIRATION DATE: 12/31/2007
RESPS:1 HOURS:1,200 COSTS(000):$0
Guidance for the Tribal Temporary Assistance for Needy Families
(TANF) Program
FORMS: NONE
OMB NO: 0970-0159 EXPIRATION DATE: 07/31/2008
RESPS:3 HOURS:600 COSTS(000):$0
Statewide Automated Child Welfare Information System (SACWIS)
Assessment Review Guide
FORMS: NONE
OMB NO: 0970-0160 EXPIRATION DATE: 12/31/2006
RESPS:10 HOURS:200 COSTS(000):$0
Procedures for Requests from Tribal Child Care Lead Agencies to
Use Child Care and Development Fund (CCDF) for Construction or
Major Renovation of Child Care Facilities
FORMS: NONE
OMB NO: 0970-0161 EXPIRATION DATE: 04/30/2007
RESPS:7,074 HOURS:2,535 COSTS(000):$128
Federal Tax Offset, Administrative Offset, and Passprot Denial
Programs
FORMS: NONE
OMB NO: 0970-0163 EXPIRATION DATE: 03/31/2007
RESPS:4 HOURS:1,120 COSTS(000):$0
Child Care and Development Fund Quarterly Financial Report
FORMS: ACF-696
OMB NO: 0970-0166 EXPIRATION DATE: 04/30/2007
RESPS:60,000,000 HOURS:1,962,431 COSTS(000):$25,000
National Directionary of New Hires
FORMS: NONE
OMB NO: 0970-0167 EXPIRATION DATE: 05/31/2009
RESPS:224 HOURS:4,480 COSTS(000):$317
Child Care Case-Level Report
FORMS: ACF-801
OMB NO: 0970-0171 EXPIRATION DATE: 06/30/2008
RESPS:862,043 HOURS:143,988 COSTS(000):$0
Required Data Elements for Paternity Establishment Affidavits
FORMS: NONE
OMB NO: 0970-0173 EXPIRATION DATE: 11/30/2007
RESPS:1 HOURS:630 COSTS(000):$80
Request for State Data Needed to Determine the Amount of a
Tribal Family Assistance Grant
FORMS: NONE
OMB NO: 0970-0174 EXPIRATION DATE: 09/30/2006
RESPS:79 HOURS:1,575 COSTS(000):$0
Native Employment Works (NEW) Program Plan Guidance and Program
Report
FORMS: NONE
OMB NO: 0970-0175 EXPIRATION DATE: 06/30/2008
RESPS:862,043 HOURS:143,099 COSTS(000):$0
Voluntary Establishment of Paternity
FORMS: NONE
OMB NO: 0970-0177 EXPIRATION DATE: 08/31/2008
RESPS:54 HOURS:378 COSTS(000):$0
OCSE-157 Child Support Enforcement Annual Data Report
FORMS: NONE
OMB NO: 0970-0181 EXPIRATION DATE: 07/31/2009
RESPS:432 HOURS:3,456 COSTS(000):$2,000
Child Support Enforcement Program Financial Report Child Support
Enforcement Program Quarterly Report of Collection
FORMS: OCSE34A OCSE396A
OMB NO: 0970-0183 EXPIRATION DATE: 04/30/2008
RESPS:648 HOURS:1,296 COSTS(000):$0
Project 1099
FORMS: NONE
OMB NO: 0970-0186 EXPIRATION DATE: 02/28/2009
RESPS:1 HOURS:15,552 COSTS(000):$0
Methodology for Determining Whether an Increase in a State's
Child Poverty Rate is the Result of the TANF Program
FORMS: NONE
OMB NO: 0970-0193 EXPIRATION DATE: 08/31/2006
RESPS:200 HOURS:8,200 COSTS(000):$0
45 CFR 1309 Head Start Facilities Purchase, Major Renovation and
Construction
FORMS: NONE
OMB NO: 0970-0195 EXPIRATION DATE: 04/30/2008
RESPS:232 HOURS:1,740 COSTS(000):$0
Child Care and Development Fund Annual Financial Report for
Tribes (CCDF)
FORMS: ACF-696T
OMB NO: 0970-0196 EXPIRATION DATE: 10/31/2007
RESPS:18,337 HOURS:9,168 COSTS(000):$17
Financial Institution Data Match
FORMS: NONE
OMB NO: 0970-0198 EXPIRATION DATE: 08/31/2008
RESPS:265 HOURS:5,035 COSTS(000):$0
Child Care and Development Fund Plan Preprint
FORMS: ACF-118-A
OMB NO: 0970-0199 EXPIRATION DATE: 09/30/2006
RESPS:332 HOURS:543,382 COSTS(000):$13,500
TANF Data Report (Includes TANF Sampling and Statistical Methods
Manual), SSP-MOE Data Report (Includes TANF Sampling and
Statistical Methods Manual)
FORMS: ACF-199 ACF-209
OMB NO: 0970-0202 EXPIRATION DATE: 06/30/2009
RESPS:950 HOURS:1,425 COSTS(000):$0
National Survey of Child and Adolescent Well-Being: Infant
Follow-Up
FORMS: NONE
OMB NO: 0970-0204 EXPIRATION DATE: 06/30/2009
RESPS:324 HOURS:4,860 COSTS(000):$0
State Child Access Program Survey
FORMS: NONE
OMB NO: 0970-0205 EXPIRATION DATE: 02/28/2009
RESPS:4 HOURS:3,536 COSTS(000):$0
IV-E Foster Care and Adoption Assistance Financial Report
FORMS: ACF-IV-E-1
OMB NO: 0970-0207 EXPIRATION DATE: 09/30/2006
RESPS:1,600 HOURS:52,800 COSTS(000):$0
Head Start Grant Application and Budget Instrument
FORMS: NONE
OMB NO: 0970-0209 EXPIRATION DATE: 03/31/2009
RESPS:1,018 HOURS:297 COSTS(000):$0
Online Interstate Referral Guide (IRG)
FORMS: NONE
OMB NO: 0970-0214 EXPIRATION DATE: 10/31/2006
RESPS:42 HOURS:14,072 COSTS(000):$0
Title IV-E Foster Care Eligibility Reviews, Child and Family
Services Reviews
FORMS: NONE
OMB NO: 0970-0215 EXPIRATION DATE: 09/30/2006
RESPS:336 HOURS:106,624 COSTS(000):$1,759
Final Tribal TANF Data Report
FORMS: ACF-343
OMB NO: 0970-0218 EXPIRATION DATE: 04/30/2007
RESPS:150 HOURS:46,462 COSTS(000):$0
Tribal Child Support Direct Funding Regulation - Final
FORMS: NONE
OMB NO: 0970-0222 EXPIRATION DATE: 02/29/2008
RESPS:726,516 HOURS:123,507 COSTS(000):$11
National Medical Support Notice
FORMS: NONE
OMB NO: 0970-0223 EXPIRATION DATE: 03/31/2007
RESPS:54 HOURS:208,764 COSTS(000):$450
State Self-Assessment Review and Report
FORMS: NONE
OMB NO: 0970-0230 EXPIRATION DATE: 02/28/2009
RESPS:108 HOURS:1,728 COSTS(000):$0
Revised Reporting Requirements and Transmission Layouts on TANF
HPB
FORMS: ACF-300
OMB NO: 0970-0234 EXPIRATION DATE: 05/31/2008
RESPS:56 HOURS:6,160 COSTS(000):$0
Social Services Block Grant Postexpenditure Report
FORMS: NONE
OMB NO: 0970-0245 EXPIRATION DATE: 06/30/2009
RESPS:52 HOURS:3,952 COSTS(000):$0
Court Improvement Program
FORMS: NONE
OMB NO: 0970-0246 EXPIRATION DATE: 01/31/2007
RESPS:1,197 HOURS:1,139 COSTS(000):$0
Rural Welfare-to-Work Strategies Demonstration Evaluation Project
FORMS: NONE
OMB NO: 0970-0247 EXPIRATION DATE: 03/31/2009
RESPS:4 HOURS:1,728 COSTS(000):$0
Temporary Assistance for Needy Families Quarterly Financial
Report
FORMS: ACF-196
OMB NO: 0970-0248 EXPIRATION DATE: 08/31/2006
RESPS:4 HOURS:32,882 COSTS(000):$0
Caseload Reduction Documentation Process, the Reasonable
Cause/Corrective Compliance Documentation Process, and the
Annual Report on State MOE Programs
FORMS: ACF-202 ACF-204
OMB NO: 0970-0249 EXPIRATION DATE: 07/31/2009
RESPS:924,458 HOURS:924,458 COSTS(000):$0
Design and Field Testing of Head Start National Reporting System
on Child Outcomes
FORMS: NONE
OMB NO: 0970-0251 EXPIRATION DATE: 07/31/2007
RESPS:5,459 HOURS:2,184 COSTS(000):$0
HHS/ACF/ASPE/DOL Enhanced Services for the Hard-to-Employ
Demonstration and Evaluation Project Baseline Survey (Revised)
FORMS: NONE
OMB NO: 0970-0253 EXPIRATION DATE: 08/31/2006
RESPS:4,500 HOURS:3,800 COSTS(000):$0
Multi-site Evaluation of Foster Youth Programs
FORMS: NONE
OMB NO: 0970-0255 EXPIRATION DATE: 07/31/2008
RESPS:56 HOURS:1,120 COSTS(000):$22
Child Care Report for High Performance Bonus
FORMS: ACF-900
OMB NO: 0970-0257 EXPIRATION DATE: 01/31/2007
RESPS:312 HOURS:499 COSTS(000):$0
"Building Strong Families Demonstration and Evaluation"
FORMS: NONE
OMB NO: 0970-0260 EXPIRATION DATE: 07/31/2009
RESPS:275 HOURS:275 COSTS(000):$0
Extension to Head Start Transportation Requirements
FORMS: NONE
OMB NO: 0970-0261 EXPIRATION DATE: 03/31/2007
RESPS:1 HOURS:18,200 COSTS(000):$0
Grants Application Data Summary Administrative for Native
Americans SEDS Applecation Information
FORMS: NONE
OMB NO: 0970-0262 EXPIRATION DATE: 03/31/2007
RESPS:443 HOURS:332 COSTS(000):$0
Migrant and Seasonal Head Start Research Design Development
Project
FORMS: NONE
OMB NO: 0970-0263 EXPIRATION DATE: 04/30/2007
RESPS:1 HOURS:18,200 COSTS(000):$0
Grant Application Data Summary Administration for Native
Americans Environmental Application Information
FORMS: NONE
OMB NO: 0970-0264 EXPIRATION DATE: 04/30/2007
RESPS:1 HOURS:18,200 COSTS(000):$0
Grant Application Data Summary Administration for Native
Americans Language Application Information
FORMS: NONE
OMB NO: 0970-0265 EXPIRATION DATE: 06/30/2007
RESPS:1 HOURS:300 COSTS(000):$0
ANA Consultant and Evaluator Qualifications Form
FORMS: NONE
OMB NO: 0970-0266 EXPIRATION DATE: 08/31/2007
RESPS:1,000 HOURS:12,500 COSTS(000):$763
Mentoring Children of Prisoners Data Collection Process (MCPDCP)
FORMS: NONE
OMB NO: 0970-0267 EXPIRATION DATE: 04/30/2008
RESPS:13,720 HOURS:2,744 COSTS(000):$0
Fourth National Incidence Study of Child Abus and Neglect (NIS-4)
FORMS: NONE
OMB NO: 0970-0268 EXPIRATION DATE: 09/30/2007
RESPS:216 HOURS:864 COSTS(000):$0
Itemized Undistributed Collections
FORMS: SCHED.-UDC
OMB NO: 0970-0271 EXPIRATION DATE: 09/30/2007
RESPS:51 HOURS:8,670 COSTS(000):$0
Section 510 State Abstinence Education Grant Program Guidance
and Forms
FORMS: NONE
OMB NO: 0970-0272 EXPIRATION DATE: 08/31/2006
RESPS:119 HOURS:714 COSTS(000):$0
Maternal and Child Health Bureau Common Grant Guidance for
Discretionay Grants
FORMS: NONE
OMB NO: 0970-0273 EXPIRATION DATE: 03/31/2008
RESPS:96,000 HOURS:29,520 COSTS(000):$0
Building Strong Families - Baseline
FORMS: NONE
OMB NO: 0970-0276 EXPIRATION DATE: 06/30/2009
RESPS:4,760 HOURS:2,973 COSTS(000):$0
Rhode Island 15-Month Follow-UP Survey Amendment
FORMS: NONE
OMB NO: 0970-0277 EXPIRATION DATE: 05/31/2008
RESPS:2,148 HOURS:3,468 COSTS(000):$0
Evaluation of the Early Head Start Enhanced Home Visiting Pilot
Project
FORMS: NONE
OMB NO: 0970-0278 EXPIRATION DATE: 06/30/2008
RESPS:108,000 HOURS:4,250 COSTS(000):$122
Family Reunification Instruments
FORMS: NONE
OMB NO: 0970-0280 EXPIRATION DATE: 10/31/2008
RESPS:286 HOURS:1,716 COSTS(000):$0
Family Violence Prevention and Services: Grants to States;
Native American Tribes and Alaskan Native Villages; and State
Domestic Violence Coalitions
FORMS: NONE
OMB NO: 0970-0281 EXPIRATION DATE: 07/31/2008
RESPS:90 HOURS:270 COSTS(000):$0
Supporting Healthy Marriage Project Focus Group Protocol
FORMS: NONE
OMB NO: 0970-0283 EXPIRATION DATE: 08/31/2008
RESPS:400 HOURS:440 COSTS(000):$0
Evaluation of the Community Healthy Marriage Initiative
Implementation Study
FORMS: NONE
OMB NO: 0970-0284 EXPIRATION DATE: 08/31/2006
RESPS:957 HOURS:1,223 COSTS(000):$0
The Head Start Training and Technical Assistance Quality
Assurance Study
FORMS: NONE
OMB NO: 0970-0285 EXPIRATION DATE: 08/31/2008
RESPS:1,750 HOURS:875 COSTS(000):$0
Employment Retention and Advancement Evaluation 42-month Survey
FORMS: NONE
OMB NO: 0970-0286 EXPIRATION DATE: 08/31/2008
RESPS:245 HOURS:237 COSTS(000):$0
Exploring the Collection of Marriage and Divorce Statistics at
the National, State, and Local Levels
FORMS: NONE
OMB NO: 0970-0287 EXPIRATION DATE: 08/31/2008
RESPS:12,500 HOURS:13,845 COSTS(000):$0
Fourth National Incidence Study of Child Abuse and Neglect
(NIS-4) 2nd submission
FORMS: NONE
OMB NO: 0970-0288 EXPIRATION DATE: 10/31/2008
RESPS:263 HOURS:1,665 COSTS(000):$0
Improving Child Welfare Outcomes through Systems of Care
FORMS: NONE
OMB NO: 0970-0289 EXPIRATION DATE: 08/31/2008
RESPS:61 HOURS:61,000 COSTS(000):$0
Annual Report on Progress - University Centers for Excellence in
Developmental Disabilities Education, Research, and Service
FORMS: NONE
OMB NO: 0970-0290 EXPIRATION DATE: 10/31/2008
RESPS:54 HOURS:1,296 COSTS(000):$0
Improper Payments Information Survey for the TANF Program
FORMS: NONE
OMB NO: 0970-0291 EXPIRATION DATE: 10/31/2008
RESPS:54 HOURS:1,296 COSTS(000):$0
Improper Payments Informaiton Survey for the CCDF Program
FORMS: NONE
OMB NO: 0970-0293 EXPIRATION DATE: 12/31/2008
RESPS:1,575 HOURS:583 COSTS(000):$0
Compassion Capital Fund Program Evaluation-Baseline and Follow-Up
FORMS: NONE
OMB NO: 0970-0295 EXPIRATION DATE: 11/30/2008
RESPS:348 HOURS:656 COSTS(000):$0
The National Evaluation of the Court Improvement Program
FORMS: NONE
OMB NO: 0970-0296 EXPIRATION DATE: 12/31/2006
RESPS:1,042 HOURS:899 COSTS(000):$0
Evaluation of Refugee Social Services (RSS) and Targeted
Assistance Formula Grant (TAG) Programs: Data Collection
FORMS: NONE
OMB NO: 0970-0297 EXPIRATION DATE: 01/31/2009
RESPS:180 HOURS:60 COSTS(000):$0
Compassion Capital Fund Evaluation-Initial Outcome Study
FORMS: NONE
OMB NO: 0970-0298 EXPIRATION DATE: 02/28/2009
RESPS:433,620 HOURS:3,878 COSTS(000):$0
Field Test of Social-Emotional Measures and Modified Assessment
Measure for the Head Start National Reporting System
FORMS: NONE
OMB NO: 0970-0299 EXPIRATION DATE: 05/31/2009
RESPS:4,000 HOURS:3,000 COSTS(000):$0
Supporting Healthy Marriage Project Baseline Data Collection
FORMS: NONE
OMB NO: 0970-0300 EXPIRATION DATE: 05/31/2009
RESPS:324 HOURS:276 COSTS(000):$0
Sanction Policies Task Order
FORMS: NONE
OMB NO: 0970-0301 EXPIRATION DATE: 06/30/2009
RESPS:113 HOURS:117 COSTS(000):$0
TANF Time Limits Interview Guides for Site Visits
FORMS: NONE
OMB NO: 0970-0302 EXPIRATION DATE: 07/31/2009
RESPS:1,680 HOURS:1,260 COSTS(000):$0
Follow-up Study of Issues Affecting the Duration of Child Care
Subsidies
FORMS: NONE
OMB NO: 0970-0303 EXPIRATION DATE: 07/31/2009
RESPS:1,498 HOURS:177 COSTS(000):$0
National Clearinghouse on Child Abuse and Neglect Information
(CAN) and NAIC
FORMS: NONE
OMB NO: 0970-0304 EXPIRATION DATE: 07/31/2009
RESPS:3,148 HOURS:2,803 COSTS(000):$0
Building Strong Families Demonstration and Evaluation -
Implementation and Impact Study
FORMS: NONE
OMB NO: 0970-0306 EXPIRATION DATE: 07/31/2009
RESPS:23,556 HOURS:3,693 COSTS(000):$0
Evaluation of Child Care Subsidy Strategies; Massachusetts,
Illinois, and Washington
FORMS: ACYF-05-00091
OMB NO: 0970-0307 EXPIRATION DATE: 12/31/2006
RESPS:208 HOURS:7,904 COSTS(000):$0
Court Improvement Program-New Grants
FORMS: SF-424 SF-424-A
SUBAGENCY TOTALS
ACTIVE ANNUAL ANNUAL ANNUAL
REPORTS RESPONSES HOURS COSTS($000)
105 64,377,599 8,610,187 $45,372
Office of Human Development Services
OMB NO: 0980-0017 EXPIRATION DATE: 04/30/2008
RESPS:2,690 HOURS:10,760 COSTS(000):$0
Head Start Program Information Report
FORMS: NONE
OMB NO: 0980-0047 EXPIRATION DATE: 10/31/2008
RESPS:1 HOURS:64,075 COSTS(000):$0
Child & Family Services Plan (CFSP). Annual Progress & Services
Report (APSR), & Annual Budget Expenses Request & Estimated
Expenditures (CFS-101)
FORMS: CFS-101
OMB NO: 0980-0140 EXPIRATION DATE: 10/31/2007
RESPS:701,461 HOURS:1,823,900 COSTS(000):$0
Case Plan Requirement, Title IV-E of the Social Security Act
FORMS: NONE
OMB NO: 0980-0141 EXPIRATION DATE: 11/30/2008
RESPS:12 HOURS:180 COSTS(000):$0
State Plan for Foster Care and Adoption Assistance: Title IV-E
of the Social Security Act
FORMS: NONE
OMB NO: 0980-0160 EXPIRATION DATE: 11/30/2008
RESPS:57 HOURS:2,508 COSTS(000):$0
Developmental Disabilities Protection and Advocacy Program
Performance Report
FORMS: NONE
OMB NO: 0980-0162 EXPIRATION DATE: 05/31/2009
RESPS:1 HOURS:4,400 COSTS(000):$0
Developmental Disabilities State Plan
FORMS: NONE
OMB NO: 0980-0172 EXPIRATION DATE: 02/28/2009
RESPS:1 HOURS:2,420 COSTS(000):$0
Developmental Disabilities Council Program Performance Report
FORMS: NONE
OMB NO: 0980-0196 EXPIRATION DATE: 11/30/2008
RESPS:52 HOURS:3,120 COSTS(000):$0
Application and Program Reporting Requirements for Children's
Justice Act Grants
FORMS: NONE
OMB NO: 0980-0204 EXPIRATION DATE: 10/31/2006
RESPS:1 HOURS:18,850 COSTS(000):$0
Objective Work Plan (OWP) and Project Abstract
FORMS: NONE
OMB NO: 0980-0212 EXPIRATION DATE: 05/31/2009
RESPS:55 HOURS:440 COSTS(000):$0
Financial Status Reporting Form for Program of State Council on
Developmental Disabilities
FORMS: ADD02/SF269-SUP
OMB NO: 0980-0229 EXPIRATION DATE: 10/31/2006
RESPS:52 HOURS:6,068 COSTS(000):$106
National Child Abuse and Neglect Data System (NCANDS)
FORMS: NONE
OMB NO: 0980-0241 EXPIRATION DATE: 12/31/2007
RESPS:263 HOURS:9,205 COSTS(000):$0
Child Care and Development Fund Tribal Annual Report
FORMS: ACF-700
OMB NO: 0980-0242 EXPIRATION DATE: 08/31/2006
RESPS:1 HOURS:260 COSTS(000):$0
45 C.F.R. 1303 Appeal Procedures for Head Start Grantees and
Current or former Delegate Agencies
FORMS: NONE
OMB NO: 0980-0243 EXPIRATION DATE: 03/31/2009
RESPS:2,700 HOURS:5,000 COSTS(000):$0
Head Start Grants Administration
FORMS: NONE
OMB NO: 0980-0266 EXPIRATION DATE: 02/29/2008
RESPS:1,028 HOURS:616 COSTS(000):$0
Voluntary Survey of Program Partners to Implement Executive
Order 12862 within the Administration for Children Families
FORMS: NONE
OMB NO: 0980-0267 EXPIRATION DATE: 08/31/2008
RESPS:2 HOURS:309,077 COSTS(000):$0
Adoption and Foster Care Analysis and Reporting System (AFCARS),
Title IV-B & IV-E
FORMS: NONE
OMB NO: 0980-0270 EXPIRATION DATE: 08/31/2006
RESPS:1 HOURS:2,508 COSTS(000):$1,710
Developmental Disabilities Protection and Advocacy Statement of
Goals and Priorities
FORMS: NONE
OMB NO: 0980-0271 EXPIRATION DATE: 01/31/2008
RESPS:3,373,359 HOURS:164,360 COSTS(000):$233
Computerized Support Enforcement Systems - Final rule
FORMS: NONE
SUBAGENCY TOTALS
ACTIVE ANNUAL ANNUAL ANNUAL
REPORTS RESPONSES HOURS COSTS($000)
18 4,081,737 2,427,747 $2,049
Administration on Aging
OMB NO: 0985-0004 EXPIRATION DATE: 08/31/2007
RESPS:112 HOURS:112 COSTS(000):$0
Supplemental Form to the Financial Status Report for all AoA
Title III Grantees
FORMS: NONE
OMB NO: 0985-0005 EXPIRATION DATE: 06/30/2009
RESPS:52 HOURS:10,258 COSTS(000):$0
State Annual Long-Term Care Ombudsman Report
FORMS: NONE
OMB NO: 0985-0006 EXPIRATION DATE: 09/30/2007
RESPS:600 HOURS:12,000 COSTS(000):$0
Performance Progress Reports for Title IV Grantees
FORMS: NONE
OMB NO: 0985-0007 EXPIRATION DATE: 08/31/2006
RESPS:2 HOURS:729 COSTS(000):$0
Program Performance Report, Title VI of the Older Americans Act.
(Grants for Native Americns for Nutritional and Supportive
Services)
FORMS: NONE
OMB NO: 0985-0008 EXPIRATION DATE: 03/31/2007
RESPS:1 HOURS:127,019 COSTS(000):$0
State Program Report for Titles III and VII of the Older
Americans Act
FORMS: NONE
OMB NO: 0985-0009 EXPIRATION DATE: 08/31/2008
RESPS:56 HOURS:28 COSTS(000):$0
Certification of Maintenance of Effort
FORMS: NONE
OMB NO: 0985-0018 EXPIRATION DATE: 03/31/2007
RESPS:500 HOURS:5,000 COSTS(000):$0
AoA Uniform Project Description
FORMS: NONE
OMB NO: 0985-0019 EXPIRATION DATE: 06/30/2007
RESPS:2,000 HOURS:500 COSTS(000):$0
AoA Nutrition and Physical Activity Campaign
FORMS: NONE
OMB NO: 0985-0021 EXPIRATION DATE: 05/31/2008
RESPS:657 HOURS:657 COSTS(000):$0
2005 National Survey of Area Agencies on Aging
FORMS: NONE
SUBAGENCY TOTALS
ACTIVE ANNUAL ANNUAL ANNUAL
REPORTS RESPONSES HOURS COSTS($000)
9 3,980 156,303 $0
Departmental Management
OMB NO: 0990-0001 EXPIRATION DATE: 08/31/2006
RESPS:200 HOURS:2,400 COSTS(000):$150
Application of Waiver of the 2 Year Foreign Residence
Requirement of the Exchange Visitor Program
FORMS: HHS-426
OMB NO: 0990-0115 EXPIRATION DATE: 11/30/2007
RESPS:5,357 HOURS:883,905 COSTS(000):$0
HHS Acquisition Regulation - Solicitation and Contracts
FORMS: NONE
OMB NO: 0990-0129 EXPIRATION DATE: 03/31/2009
RESPS:1,242 HOURS:10,556 COSTS(000):$0
Special Programs Affecting Acquisition (HHSAR Part 370)
FORMS: NONE
OMB NO: 0990-0130 EXPIRATION DATE: 03/31/2009
RESPS:1,921 HOURS:3,842 COSTS(000):$0
Solicitation Provisions and Contracts Clauses (HHSAR Part 352)
FORMS: NONE
OMB NO: 0990-0131 EXPIRATION DATE: 06/30/2009
RESPS:110 HOURS:2,200 COSTS(000):$0
HHS Acquisition Regulation - HHSAR Part 342 - Contract
Administration
FORMS: NONE
OMB NO: 0990-0133 EXPIRATION DATE: 03/31/2009
RESPS:1 HOURS:40 COSTS(000):$0
HHS Acquisition Regulation - HHSAR Part 333 - Disputes and
Appeals
FORMS: NONE
OMB NO: 0990-0136 EXPIRATION DATE: 08/31/2006
RESPS:430 HOURS:3,440 COSTS(000):$0
HHS Acquisition Regulation - HHSAR Part 324 - Protection of
Privacy and Freedom of Information
FORMS: NONE
OMB NO: 0990-0150 EXPIRATION DATE: 09/30/2007
RESPS:1 HOURS:1 COSTS(000):$0
Uniform Relocation and Real Property Acquisition Under Federal
and Federally Assisted programs
FORMS: NONE
OMB NO: 0990-0162 EXPIRATION DATE: 03/31/2007
RESPS:48 HOURS:2,744 COSTS(000):$0
State Medicaid Fraud Control Units Annual Report and
Recertification Application
FORMS: NONE
OMB NO: 0990-0169 EXPIRATION DATE: 08/31/2006
RESPS:4,000 HOURS:280,000 COSTS(000):$0
Uniform Administrative Requirements for Grantrs and Cooperative
Agreements to State and Local Governments
FORMS: NONE
OMB NO: 0990-0208 EXPIRATION DATE: 05/31/2009
RESPS:30,000 HOURS:1,000 COSTS(000):$0
Applicant Background Survey
FORMS: NONE
OMB NO: 0990-0220 EXPIRATION DATE: 01/31/2007
RESPS:8,180 HOURS:1,577 COSTS(000):$0
Voluntary Industry Partner Surveys to Implement E.O. 12862
FORMS: NONE
OMB NO: 0990-0221 EXPIRATION DATE: 04/30/2007
RESPS:89 HOURS:2,937 COSTS(000):$1,036
Family Planning Annual Report: Forms and Instructions
FORMS: NONE
OMB NO: 0990-0243 EXPIRATION DATE: 06/30/2007
RESPS:4,000 HOURS:64,000 COSTS(000):$0
OCR Pre-granted Automation Project
FORMS: NONE
OMB NO: 0990-0260 EXPIRATION DATE: 12/31/2008
RESPS:446,334 HOURS:1,105,834 COSTS(000):$0
Protection of Human Subjects: Common Rule (56 FR 28003)
FORMS: NONE
OMB NO: 0990-0263 EXPIRATION DATE: 11/30/2008
RESPS:166,667 HOURS:55,500 COSTS(000):$0
Protection of Human Subjects Assurance Identification/IRB
Certification/Declaration of Exemption
FORMS: NONE
OMB NO: 0990-0268 EXPIRATION DATE: 03/31/2009
RESPS:5,437 HOURS:2,513 COSTS(000):$0
Service Use and Transition of Private Long-term Care Insurance
FORMS: NONE
OMB NO: 0990-0269 EXPIRATION DATE: 07/31/2009
RESPS:12,400 HOURS:9,300 COSTS(000):$0
Complaint Forms for Discrimination; Health Information Privacy
Complaints
FORMS: NONE
OMB NO: 0990-0273 EXPIRATION DATE: 03/31/2007
RESPS:1,352 HOURS:286 COSTS(000):$0
Evaluation of the Office of Minority Health Resource Center
FORMS: NONE
OMB NO: 0990-0274 EXPIRATION DATE: 03/31/2007
RESPS:173 HOURS:175 COSTS(000):$0
Survey of State and Local Contracting Officials on Contracting
for Social Services Under Charitable Choices
FORMS: NONE
OMB NO: 0990-0275 EXPIRATION DATE: 06/30/2007
RESPS:616 HOURS:2,772 COSTS(000):$0
Implementation of an Internet & Paper-Based Uniform Data Set for
OMH-funded Activities
FORMS: NONE
OMB NO: 0990-0276 EXPIRATION DATE: 08/31/2007
RESPS:301 HOURS:75 COSTS(000):$0
Assessment Study of the Uses of Healthier US and Healthy People
2010
FORMS: NONE
OMB NO: 0990-0278 EXPIRATION DATE: 01/31/2008
RESPS:30,000 HOURS:22,500 COSTS(000):$0
Federalwide Assurance (FWA)
FORMS: NONE
OMB NO: 0990-0279 EXPIRATION DATE: 01/31/2008
RESPS:5,000 HOURS:3,500 COSTS(000):$0
Institutional Review Board/Independent Ethics Committee
Registration Form
FORMS: NONE
OMB NO: 0990-0280 EXPIRATION DATE: 04/30/2008
RESPS:3,900 HOURS:1,300 COSTS(000):$0
Reporting Suspected Research Misconduct in Biomedical and
Behavioral Research
FORMS: NONE
OMB NO: 0990-0281 EXPIRATION DATE: 06/30/2008
RESPS:1,742 HOURS:4,200 COSTS(000):$0
Prevention Communication Formative Research
FORMS: NONE
OMB NO: 0990-0282 EXPIRATION DATE: 03/31/2008
RESPS:2,569 HOURS:1,285 COSTS(000):$0
Wave 4 Survey of Youth for the Federal Evaluation of Initiatives
Funded Under SEction 510 of the Maternal and Child Health Block
Grant
FORMS: NONE
OMB NO: 0990-0285 EXPIRATION DATE: 06/30/2008
RESPS:25 HOURS:50 COSTS(000):$0
Office for Human Research Protections, Fellowship Program
FORMS: NONE
OMB NO: 0990-0286 EXPIRATION DATE: 08/31/2008
RESPS:30 HOURS:30 COSTS(000):$0
Homeless, Veterans, Women, Healthcare
FORMS: NONE
OMB NO: 0990-0287 EXPIRATION DATE: 06/30/2008
RESPS:4 HOURS:19,728 COSTS(000):$0
HHS Research Misconduct Final Rule
FORMS: NONE
OMB NO: 0990-0288 EXPIRATION DATE: 08/31/2008
RESPS:392,650 HOURS:3,510 COSTS(000):$0
National Heart, Lung, and Blood Institute (NHLBI) The Heart
Truth Professional Education Campaign Provider Pretest/Posttest
FORMS: NONE
OMB NO: 0990-0289 EXPIRATION DATE: 09/30/2008
RESPS:260 HOURS:1,635 COSTS(000):$0
Evaluation of HIV Prevention Programs for Women
FORMS: NONE
OMB NO: 0990-0290 EXPIRATION DATE: 09/30/2008
RESPS:12,600 HOURS:6,300 COSTS(000):$0
Adolescent Family Life Care Program Core Evaluation
FORMS: NONE
OMB NO: 0990-0291 EXPIRATION DATE: 09/30/2008
RESPS:83,000 HOURS:41,500 COSTS(000):$0
Adolescent Family Life Pregnancy Prevention Core Evaluation
FORMS: NONE
OMB NO: 0990-0292 EXPIRATION DATE: 10/31/2008
RESPS:8,448 HOURS:2,112 COSTS(000):$0
Burn Bed Enumeration
FORMS: NONE
OMB NO: 0990-0294 EXPIRATION DATE: 03/31/2009
RESPS:776,224,162 HOURS:2,210,715 COSTS(000):$0
Standards for Privacy of Individually Identifiable Health
Information and Supporting Regulations at 45 CFR Parts 160 and
164
FORMS: NONE
OMB NO: 0990-0295 EXPIRATION DATE: 01/31/2009
RESPS:845 HOURS:453 COSTS(000):$0
Survey of Frontline Supervisors of Direct Service Workers
Participating in the Better Jobs Better Care Demonstration
FORMS: NONE
OMB NO: 0990-0296 EXPIRATION DATE: 02/28/2009
RESPS:390 HOURS:98 COSTS(000):$0
National Community Centers of Excellence in Women's Health and
National Centers of Excellence in Women's Health Joint Project
Evaluation/Participant Survey
FORMS: NONE
OMB NO: 0990-0297 EXPIRATION DATE: 02/28/2009
RESPS:170 HOURS:43 COSTS(000):$0
National Community Centers of Excellence in Women's Health and
National Centers of Excellence in Women's Health Joint Project
Evaluation/Professional/Professional Surveys
FORMS: NONE
OMB NO: 0990-0299 EXPIRATION DATE: 05/31/2009
RESPS:50 HOURS:106 COSTS(000):$0
Adolescent Family Life Care Demonstration Project End of Year
Care Template (EOYC)
FORMS: NONE
OMB NO: 0990-0300 EXPIRATION DATE: 05/31/2009
RESPS:60 HOURS:65 COSTS(000):$0
Adolescent Family Life Prevention Demonstration Project End of
Year Template
FORMS: NONE
OMB NO: 0990-0302 EXPIRATION DATE: 06/30/2009
RESPS:2,700 HOURS:2,700 COSTS(000):$0
Medical Reserve Corps (MRC) Unit Profile and Reports
FORMS: NONE
OMB NO: 0990-0303 EXPIRATION DATE: 07/31/2009
RESPS:2,800 HOURS:700 COSTS(000):$0
National Women's Health Week (NWHW) Survey
FORMS: NONE
OMB NO: 0990-0304 EXPIRATION DATE: 10/31/2006
RESPS:5,790 HOURS:3,785 COSTS(000):$0
National Outcomes Performance Assessment of the Collaborative
Initiative to Help End Chronic Homelessness
FORMS: NONE
SUBAGENCY TOTALS
ACTIVE ANNUAL ANNUAL ANNUAL
REPORTS RESPONSES HOURS COSTS($000)
44 777,466,054 4,761,412 $1,186
Office of Family Assistance
OMB NO: 0992-0003 EXPIRATION DATE: 04/30/2009
RESPS:41,300 HOURS:998 COSTS(000):$0
April 2006 Current Population Survey Supplement on Child Support
FORMS: NONE
OMB NO: 0992-0005 EXPIRATION DATE: 04/30/2008
RESPS:260 HOURS:5,751 COSTS(000):$0
45 CFR Part 95, Subpart F--Automatic Data Processing Equipment &
Services--Condition for Federal Financial Participation
FORMS: NONE
OMB NO: 0992-0007 EXPIRATION DATE: 05/31/2008
RESPS:216 HOURS:4,320 COSTS(000):$0
TANF High Performance Bonus Report, Assessment of Medicaid and
SCHIP Enrollment Aming Individuals After Leaving TANF Assistance
FORMS: ACF-210
OMB NO: 0992-0008 EXPIRATION DATE: 12/31/2007
RESPS:1,120 HOURS:2,547 COSTS(000):$0
Survey of Early Head Start Programs
FORMS: NONE
SUBAGENCY TOTALS
ACTIVE ANNUAL ANNUAL ANNUAL
REPORTS RESPONSES HOURS COSTS($000)
4 42,896 13,616 $0
AGENCY TOTALS:
ACTIVE ANNUAL ANNUAL ANNUAL
REPORTS RESPONSES HOURS COSTS($000)
952 8,602,796,386 655,499,763 $1,014,642
