Information Collection

Physician and Beneficiary Survey for the Evaluation of the Low Vision Rehabilitation Demonstration (Patient interviews)

IC 183401 under ICR 200801-0938-006 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10218 Attach #2 (LVS) Phone ATT1256300.doc	Other-Telephone Survey
CMS-10218 Attach #3 (LVS) Mail ATT1256301.doc	Other-Mail Survey

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
Other-Telephone Survey			CMS-10218 Attach #2 (LVS) Phone ATT1256300.doc		Yes	Yes	Paper Only
Other-Mail Survey			CMS-10218 Attach #3 (LVS) Mail ATT1256301.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 144

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	144	144
Annual IC Time Burden (Hours)	72	72
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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