Assessing Degrees of Health Care Involvement Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Assessing Degrees CMS-10208	Form and Instruction	New	Available
Form CMS-10208 Assessing Degrees of Health Care Involvement Survey	Form and Instruction	New	Available
Supporting Statement Attachment B.doc	Supporting Statement B	Uploaded 0000-00-00	Available
CMS-10208 PA OMB statement 7 17 2006.doc	Supporting Statement A	Uploaded 0000-00-00	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
179013	Assessing Degrees of Health Care Involvement Survey	Form and Instruction	New	CMS-10208
179013	Assessing Degrees of Health Care Involvement Survey	Form and Instruction	New	Assessing Degrees of Health Care Involvement Survey
179013	Assessing Degrees of Health Care Involvement Survey	Other-Patient Activation Survey	New

ICR Details

OMB Control No: 0938-1021	ICR Reference No: 200703-0938-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Assessing Degrees of Health Care Involvement Survey
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/17/2007
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/13/2007
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2009	36 Months From Approved
Responses	3,500	0	0
Time Burden (Hours)	1,200	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: It is not enough to merely mail information about the Medicare program to each beneficiary. We need to know not only that the beneficiaries got the information, but also that they understood the information and are able to use it in making choices about their Medicare participation. To this end, CMS must have measure(s) over time of what beneficiaries know and understand about the Medicare program now to be able to quantify and attribute any changes to their understanding or behavior to information/education initiatives. Measuring beneficiary information needs and knowledge over time will help us to evaluate the impact of information/education and other initiatives as well as to understand how the population is changing apart from such initiatives.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 63019	10/27/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 1537	01/12/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Assessing Degrees of Health Care Involvement Survey	CMS-10208, Assessing Degrees of Health Care Involvement Surve	Assessing Degrees of Health Care Involvement Survey ,   CMS-10208

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,500	0	0	3,500	0	0
Annual Time Burden (Hours)	1,200	0	0	1,200	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The objective of this research is to assess the degree to which people with Medicare actively participate in their own health and health care decisions and secondly to identify the various segments of 'self-directed patient activation' necessary to be able to tailor outreach messages to appropriate segments of the Medicare population.

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Annual Cost to Federal Government: $175,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/13/2007

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