Request for Employment Information

Forms and Documents

Document Name	Status
Form CMS-R-297 (CMS-L56 Request for Employment Information Form and Instruction	Modified
Justification for Collecting SSNs.doc Supplementary Document	2014-01-04
Crosswalk of changes 0938-0787 CMS-R-297.CMS-L5654 30-day comment period.pdf Supplementary Document	2014-01-04
CMS-R-297 - Supporting Statement A [rev 01-03-2014 by OSORA PRA].doc Supporting Statement A	2014-01-04

IC Document Collections

IC ID	Document Title	Status
8554	Request for Employment Information Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0787	ICR Reference No: 201401-0938-002
Status: Historical Active	Previous ICR Reference No: 201308-0938-009
Agency/Subagency: HHS/CMS	Agency Tracking No: 21281
Title: Request for Employment Information
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/12/2014
	Date Received in OIRA: 01/06/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2016	36 Months From Approved	09/30/2016
Responses	15,000	0	15,000
Time Burden (Hours)	5,000	0	3,750
Cost Burden (Dollars)	0	0	0

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Abstract: This information is needed to determine whether an individual is eligible to enroll in Medicare Part B or Premium Part A under the provisions of section 1837(i) of the Social Security Act (The Act) and/or qualify for a reduction in the premium amount under the provisions of section 1839(b) of the Act.

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Authorizing Statute(s): US Code: 42 USC 1395p Name of Law: Enrollment Periods
   Statute at Large: 18 Stat. 1837 Name of Statute: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 63208	10/23/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 140	01/02/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Request for Employment Information	CMS-R-297 (CMS-L564), CMS-R-297 (CMS-L564) SP	Request for Employment Information ,   Solicitud De Informaciobre El Empleo

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	15,000	15,000	0	0	0	0
Annual Time Burden (Hours)	5,000	3,750	0	1,250	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There is a change in the burden to the time the applicant spends filling out a small section of the form prior to sending the form to the employer for completion. The revised form requires the applicant to fill out Section A. While this activity may have occurred with the previous form, it was not captured in previous burden estimates. We estimate it will take the applicant 5 minutes to fill out Section A of the form. The change in the burden is due to adjustments in the form and operational processes.

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Annual Cost to Federal Government: $30,713

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

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

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

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

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/06/2014

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