Medicare Health Survey (MHS) and Data Collection for Administering the PACE Health Survey to Beneficiaries Enrolled in PACE and the Dual Eligible Demonstrations

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	Medicare Health Survey (MHS) and Data Collection for Administering the PACE Health Survey to Beneficiaries Enrolled in PACE and the Dual Eligible Demonstrations	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	CMS-10024				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15,859	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10,785	4,971	5,814
Annual IC Time Burden (Hours)	1,798	716	1,082
Annual IC Cost Burden (Dollars)	0	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.