Information Collection

Evaluation of the Medical Adult Day-Care Services Demonstration - Phase I

IC 178664 under ICR 200702-0938-003 · OMB 0938-1017.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1017 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10204 Evaluation of the Medical Adult Day-Care Services Demonstration - Phase I Form and Instruction
CMS-10204 CMS-10204 - Instruments (Appendices B,C,D,E) CMS-10204.Draft Supporting Statement.8-1-06.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Evaluation of the Medical Adult Day-Care Services Demonstration - Phase I	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-10204	CMS-10204 - Instruments (Appendices B,C,D,E)	CMS-10204.Draft Supporting Statement.8-1-06.doc		No	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5	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: 55 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	260	260
Annual IC Time Burden (Hours)	260	260
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.