Information Collection

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

IC 178664 under ICR 200805-0938-005 · OMB 0938-1017.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
REVISEDfinalOMB1.25.08supportingstatement.doc	Other-Form, Instructions and Appendi

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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-Form, Instructions and Appendices (CMS-10204)					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 %

table that charts list of burden
	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

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.

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