Information Collection

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

IC 8171 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⚠️ Notice: This information collection may be referencing outdated material.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

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: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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: 15,400	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	46,200	-3,300	49,500
Annual IC Time Burden (Hours)	46,970	-3,355	50,325
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.