Evaluation of the Medical Adult Day Care Services Demonstration (CMS-10204)

Evaluation of the Medical Adult Day Care Services Demonstration

Documents and Forms

Document Name Document Type
REVISEDfinalOMB1.25.08supportingstatement.doc Other-Form, Instructions and Appendi

Information Collection (IC) Details

IC Title:	Evaluation of the Medical Adult Day Care Services Demonstration (CMS-10204)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Form, Instructions and Appendices (CMS-10204)			REVISEDfinalOMB1.25.08supportingstatement.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 900	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	900	640	260
Annual IC Time Burden (Hours)	150	-110	260
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.