Information Collection

Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)

IC 178995 under ICR 200703-0938-003 · OMB 0938-0568.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0568 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-P-0015A Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)	Form and Instruction
CMS-P-0015A Background Questionnaire 08-F_Background_BQ.pdf	Form and Instruction
CMS-P-0015A MCBS Facility Round 46 Expenditure Questionnaire 08-F_Expenditures_EX.pdf	Form and Instruction
CMS-P-0015A MCBS Facility Round 46 Health Ins Questionnaire 08-F_Health Insurance_IN.pdf	Form and Instruction
CMS-P-0015A MCBS Facility Round 46 Health Status Base Line 08-F_Health Status_HS.pdf	Form and Instruction
CMS-P-0015A MCBS Facility Round 46 Resident History 08-F_Residence History_RH.pdf	Form and Instruction
CMS-P-0015A MCBS Facility Round 46 Prescription Medicines 08-F_Prescribed Medicines_PM.pdf	Form and Instruction
CMS-P-0015A MCBS Facility Round 46 Use of Services Module 08-F_Use of Health Care Services_US.pdf	Form and Instruction
CMS-P-0015A Facility Screening Interview Script 07-F_Facility Questionnaire_FQ.pdf	Form and Instruction
CMS-P-0015A MCBS Household Round 46 Questionnaire English 05-Questionnaire English.zip	Form and Instruction
CMS-P-0015A MCBS Household Round 46 Questionnaire Spanish 05-Questionnaire Spanish.zip	Form and Instruction
CMS-P-0015A MCBS Household Round 46 Show Cards 05-Showcards.zip	Form and Instruction
attachment 06.pdf MCBS Calendars for Supplemental and Continuing Samples	IC Document
06-2006-2007 Supplemental.pdf Calendar for Supplemental Samples	IC Document
06-2007 Continuing.pdf Calendar for Continuing Samples	IC Document
04-CMS Advance Letter with letterhead.pdf Advance Letter	IC Document
04-MCBS At the Door Sheet.pdf At the door sheet	IC Document
04-MCBS Brochure.pdf MCBS Brochure	IC Document
04-MCBS Confidentiality Agreement.pdf Confidentiality Agreement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Medicare Current Beneficiary Survey (MCBS): Rounds 48-56 (CMS Number CMS-P-0015A)

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-P-0015A	Background Questionnaire	08-F_Background_BQ.pdf	Yes	Yes	Paper Only
Form and Instruction	CMS-P-0015A	MCBS Facility Round 46 Expenditure Questionnaire	08-F_Expenditures_EX.pdf	Yes	Yes	Paper Only
Form and Instruction	CMS-P-0015A	MCBS Facility Round 46 Health Ins Questionnaire	08-F_Health Insurance_IN.pdf	Yes	Yes	Paper Only
Form and Instruction	CMS-P-0015A	MCBS Facility Round 46 Health Status Base Line	08-F_Health Status_HS.pdf	Yes	Yes	Paper Only
Form and Instruction	CMS-P-0015A	MCBS Facility Round 46 Resident History	08-F_Residence History_RH.pdf	Yes	Yes	Paper Only
Form and Instruction	CMS-P-0015A	MCBS Facility Round 46 Prescription Medicines	08-F_Prescribed Medicines_PM.pdf	Yes	Yes	Paper Only
Form and Instruction	CMS-P-0015A	MCBS Facility Round 46 Use of Services Module	08-F_Use of Health Care Services_US.pdf	Yes	Yes	Paper Only
Form and Instruction	CMS-P-0015A	Facility Screening Interview Script	07-F_Facility Questionnaire_FQ.pdf	Yes	Yes	Paper Only
Form and Instruction	CMS-P-0015A	MCBS Household Round 46 Questionnaire English	05-Questionnaire English.zip	Yes	Yes	Paper Only
Form and Instruction	CMS-P-0015A	MCBS Household Round 46 Questionnaire Spanish	05-Questionnaire Spanish.zip	Yes	Yes	Paper Only
Form and Instruction	CMS-P-0015A	MCBS Household Round 46 Show Cards	05-Showcards.zip	Yes	Yes	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,100

Number of Respondents for Small Entity: 100

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,300	3,300
Annual IC Time Burden (Hours)	3,355	3,355
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
MCBS Calendars for Supplemental and Continuing Samples	attachment 06.pdf
Calendar for Supplemental Samples	06-2006-2007 Supplemental.pdf
Calendar for Continuing Samples	06-2007 Continuing.pdf
Advance Letter	04-CMS Advance Letter with letterhead.pdf
At the door sheet	04-MCBS At the Door Sheet.pdf
MCBS Brochure	04-MCBS Brochure.pdf
Confidentiality Agreement	04-MCBS Confidentiality Agreement.pdf

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