Information Collection

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

IC 178665 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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: 50

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	38	38
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.