Information Collection

Intake And Follow-up Survey Of Medicare Beneficiaries In Staff-assisted Home Dialysis Demonstration

IC 114062 under ICR 199203-0938-006 · OMB 0938-0606.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

INTAKE AND FOLLOW-UP SURVEY OF MEDICARE BENEFICIARIES IN STAFF-ASSISTED HOME DIALYSIS DEMONSTRATION

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-R-7				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,320

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,320	1,320
Annual IC Time Burden (Hours)	440	440
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

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