Information Collection

HIFA Evaluation Enrollee Survey (CMS-10262)

IC 185371 under ICR 200806-0938-004 · OMB 0938-1055.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10262 HIFA Enrollee Survey--REVISED 011609--submitted to CMS.doc	Other-Telephone 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-10262 HIFA Enrollee Survey--REVISED 011609--submitted to CMS.doc		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 800

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
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	400	400
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.