Environmental Health Hazards Checklist

Environmental Health Hazards Checklist Medicare Coverage for Individuals Exposed to Environmental Health Hazards (CMS-10902)

Documents and Forms

Document Name Document Type
Form CMS-10902 Environmental Health Hazards Checklist Form and Instruction
CMS-10902 Environmental Health Hazards Checklist (English) CMS-XXXX-Environmental Health Hazards Checklist.docx Form and Instruction
CMS-10902 Environmental Health Hazards Checklist (Spanish) CMS-XXXX-S-Environmental Health Hazards Checklist.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Environmental Health Hazards Checklist	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10902	Environmental Health Hazards Checklist (English)	CMS-XXXX-Environmental Health Hazards Checklist.docx		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10902	Environmental Health Hazards Checklist (Spanish)	CMS-XXXX-S-Environmental Health Hazards Checklist.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: SSA’s Master Beneficiary Record (MBR)	FR Citation: 83 FR 54969

Number of Respondents: 61	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	61	61
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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