Information Collection

Assessing Degrees of Health Care Involvement Survey

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10208 Assessing Degrees of Health Care Involvement Survey	Form and Instruction
Patient Activation Survey Domains--07 11 07.doc	Other-Patient Activation Survey
CMS-10208 Assessing Degrees of Health Care Involvement Survey CMS-10208 PA Suvey 1 25 06.doc	Form and Instruction
Assessing Degrees CMS-10208 Assessing Degrees of Health Care Involvement Survey 7 11 07R.DOC	Form and Instruction
PRENOTIFICATION LETTER and Post card.doc Prenotification Letter and Post Card	IC Document

IC Title:

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-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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,500	3,500
Annual IC Time Burden (Hours)	1,200	1,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.