Data Collection for Administering the Medicare Health Improvement Survey - CMS-10202

Data Collection for Administering the Medicare Health Improvement Survey

Documents and Forms

Document Name Document Type
Form CMS-10202 Data Collection for Administering the Medicare Health Improvement Survey - CMS-10202 Form and Instruction
CMS-10202 Medicare Health Improvement Survey Instrument and Instuctions.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Data Collection for Administering the Medicare Health Improvement Survey - CMS-10202	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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 and Instruction	CMS-10202	Medicare Health Improvement Survey	Instrument and Instuctions.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,633	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	3,633	3,633
Annual IC Time Burden (Hours)	908	908
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.