OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Data Collection For Administering The Medicarecontinuity Assessment Record And Evaluation (care) Instrument (ltch)

IC 183088 under ICR 200712-0938-004 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form CMS-10243
DATA COLLECTION FOR ADMINISTERING THE MEDICARECONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (LTCH)		 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

Information Collection (IC) Details

View Information Collection (IC)

layout table

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

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Requested 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 5,302 0 5,302 0 0 0
Annual IC Time Burden (Hours) 3,975 0 3,975 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 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.