Laboratory Personnel Report (CLIA) and Supporting Regulations (CMS-209)

Forms and Documents

Document Name	Status
Form CMS-209 Laboratory Personnel Report (CLIA) and Supporting Regulations in 42 CFR 493.1 - 493.2001 Form and Instruction	Modified
Form CMS-209 Laboratory Personnel Report (CMS-209) Form and Instruction	Modified
Form CMS-209 Laboratory Personnel Report (CLIA) and Supporting Regulations in 42 CFR 493.1-493.2001 (CMS-209) Form and Instruction	Modified
CMS-209 Supporting Statement A.docx Supporting Statement A	2018-08-16

IC Document Collections

IC ID	Document Title	Status
7865	Laboratory Personnel Report (CLIA) and Supporting Regulations in 42 CFR 493.1 - 493.2001 Form and Instruction	Modified
186047	Laboratory Personnel Report (CMS-209) Form and Instruction	Modified
186046	Laboratory Personnel Report (CLIA) and Supporting Regulations in 42 CFR 493.1-493.2001 (CMS-209) Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0151	ICR Reference No: 201803-0938-006
Status: Active	Previous ICR Reference No: 201502-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Laboratory Personnel Report (CLIA) and Supporting Regulations (CMS-209)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/10/2018
	Date Received in OIRA: 03/27/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2021	36 Months From Approved	09/30/2018
Responses	9,593	0	9,526
Time Burden (Hours)	4,796	0	4,763
Cost Burden (Dollars)	0	0	0

---

Abstract: This form is used by the State agency to determine a laboratory's compliance with personnel qualifications under CLIA. This information is needed for a laboratory's CLIA certification and recertification.

---

Authorizing Statute(s): PL: Pub.L. 100 - 578 353 Name of Law: Certification of Laboratories
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 1037	01/09/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 11753	03/16/2018
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Laboratory Personnel Report (CLIA) and Supporting Regulations in 42 CFR 493.1 - 493.2001	CMS-209	Laboratory Personnel Report (CLIA)
Laboratory Personnel Report (CLIA) and Supporting Regulations in 42 CFR 493.1-493.2001 (CMS-209)	CMS-209	Laboratory Personnel Report (CLIA)
Laboratory Personnel Report (CMS-209)	CMS-209	Laboratory Personnel Report (CLIA)

---

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	9,593	9,526	0	0	67	0
Annual Time Burden (Hours)	4,796	4,763	0	0	33	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: The changes in burden are the result of an increase in the numbers of respondents in the CLIA program (i.e. 132 additional laboratory facilities that have a CLIA certificate of compliance). The respondents increased from 19,051 to 19,183. The burden hours increased from 4,763 to 4796.

---

Annual Cost to Federal Government: $3,000

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

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

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

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

---

Common Form ICR:  No

---

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: 03/27/2018

---