Information Collection

DATA COLLECTION FOR ADMINISTERING THE MEDICARE CONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (volunteers)

IC 183086 under ICR 200712-0938-004 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10243 DATA COLLECTION FOR ADMINISTERING THE MEDICARE CONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (volunteers)	Form and Instruction
CMS-10243 CARE Tool CMS-10243.Appendix B MASTER CARE Tool 30 Day Revisions 103107.doc	Form and Instruction
CAREPrototypeScreens20070716.ppt CAREPrototypeScreens20070716	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10243	CARE Tool	CMS-10243.Appendix B MASTER CARE Tool 30 Day Revisions 103107.doc		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 238

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	149,940	149,940
Annual IC Time Burden (Hours)	112,500	112,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CAREPrototypeScreens20070716	CAREPrototypeScreens20070716.ppt	11/15/2007

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