Information Collection

Questionnaire To Conduct Periodic National State-specific Medicare Beneficiary Surveys

IC 116750 under ICR 199209-0990-001 · OMB 0990-0181.

Documents and Forms

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Document Name	Document Type

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IC Title:

QUESTIONNAIRE TO CONDUCT PERIODIC NATIONAL STATE-SPECIFIC MEDICARE BENEFICIARY SURVEYS

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

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,090

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	2,090	2,090
Annual IC Time Burden (Hours)	697	697
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.