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

ICR 200409-0938-006

OMB: 0938-0844

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0844 200409-0938-006
Historical Active 200309-0938-007
HHS/CMS
Medicare Health Survey (MHS) and Data Collection for Administering the PACE Health Survey to Beneficiaries Enrolled in PACE and the Dual Eligible Demonstrations
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 09/23/2004
Retrieve Notice of Action (NOA) 09/23/2004
  Inventory as of this Action Requested Previously Approved
09/30/2004 09/30/2004 03/31/2005
10,785 0 10,785
1,798 0 1,798
0 0 0

The Centers for Medicare & Medicaid Services has developed a survey, the PHS, that is similar to the Health Outcomes Survey (HOS). This survey was approved for PACE and the Wisconsin Partnership Program (WPP) on March 14, 2003. OMB also approved the use of the PHS to beneficiaries enrolled in Minnesota Senior Health Options and Minnesota Disability Health Options (MSHO/MnDHO) on June 3, 2003 for a 6-month period. This PRA submission combines OMB approval for PACE, WPP 0938-0844 with OMB approval for MSHO/MnDHO 0938-0899 and requests to administer the PHS to beneficiaries enrolled in.....

None
None


No

  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 10,785 10,785 0 0 0 0
Annual Time Burden (Hours) 1,798 1,798 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
Yes Part B of Supporting Statement
No
Uncollected
Uncollected
Uncollected
Uncollected

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
09/23/2004


© 2024 OMB.report | Privacy Policy