OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Assessing Degrees of Health Care Involvement Survey

IC 179013 under ICR 200703-0938-004 · OMB 0938-1021.

Documents and Forms
Document Name
Document Type
Form and Instruction
Other-Patient Activation Survey
Form and Instruction
Form and Instruction
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Assessing Degrees of Health Care Involvement Survey
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10208 Assessing Degrees of Health Care Involvement Survey CMS-10208 PA Suvey 1 25 06.doc Yes Yes Paper Only
Form and Instruction Assessing Degrees of Health Care Involvement Surve CMS-10208 Assessing Degrees of Health Care Involvement Survey 7 11 07R.DOC Yes Yes Paper Only
Other-Patient Activation Survey Patient Activation Survey Domains--07 11 07.doc Yes Yes Paper Only

Health Health Care Services

 

4,000 0
   
Individuals or Households
 
   0 %

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

Title Document Date Uploaded
Prenotification Letter and Post Card PRENOTIFICATION LETTER and Post card.doc
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.