Information Collection

Survey Of Applicants To The Program Of All-inclusive Care For The Elderly (pace)

IC 114125 under ICR 199409-0938-002 · OMB 0938-0662.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	SURVEY OF APPLICANTS TO THE PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA R-165				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,561	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,727	3,727
Annual IC Time Burden (Hours)	2,825	2,825
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

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