Information Collection

HIFA Evaluation Enrollee Survey (CMS-10262)

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

Documents and Forms

Document Name Document Type
CMS-10262 HIFA Enrollee Survey--REVISED 011609--submitted to CMS.doc Other-Telephone Survey

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HIFA Evaluation Enrollee Survey (CMS-10262)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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-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 %

	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

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.