Information Collection

Mail Survey of Medicare Advantage Special Needs Plans / Focus Groups with Enrollees of Medicare Advantage SNPs

IC 45543 under ICR 200610-0938-005 · OMB 0938-1010.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10194 Mail Survey of Medicare Advantage Special Needs Plans / Focus Groups with Enrollees of Medicare Advantage SNPs	Form and Instruction
CMS-10194 SNP-OMB Appx C Focus Group Bene Form CMS-10194 REVISED SNP-OMB Appx C FocusGroupBeneForm.doc	Form and Instruction
CMS-10194 SNP-OMB Appx C FocusGroupBeneForm SNP-OMB Appx C FocusGroupBeneForm.pdf	Form and Instruction
CMS-10194 FocuGroupModeratorGuide SNP-OMB Appx B FocuGroupModeratorGuide.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10194	SNP-OMB Appx C FocusGroupBeneForm	SNP-OMB Appx C FocusGroupBeneForm.pdf	No	No	Paper Only
Form and Instruction	CMS-10194	FocuGroupModeratorGuide	SNP-OMB Appx B FocuGroupModeratorGuide.pdf	No	No	Paper Only
Form and Instruction	CMS-10194	SNP-OMB Appx C Focus Group Bene Form	CMS-10194 REVISED SNP-OMB Appx C FocusGroupBeneForm.doc	No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

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	200	200
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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