Information Collection

MPAF Data and Supporting Regulations in 42 CFR Sections 413.337, 413.343, 424.32 and 483.20

IC 188651 under ICR 200904-0938-002 · OMB 0938-0739.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-250 MPAF Data and Supporting Regulations in 42 CFR Sections 413.337, 413.343, 424.32 and 483.20	Form
MDS20MDSAllForms 32.pdf	Other-Form page 2
MDS20MDSAllForms 33.pdf	Other-Form page 3
MDS20MDSAllForms 34.pdf	Other-Form page 4
MDS20MDSAllForms 35.pdf	Other-Form page 5
CMS-R-250 MDS Medicare PPS Assessment Form MDS20MDSAllForms 31.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 413.337 42 CFR 413.343 42 CFR 424.32 42 CFR 483.20

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-R-250	MDS Medicare PPS Assessment Form	MDS20MDSAllForms 31.pdf	Yes	Yes	Paper Only
Other-Form page 2			MDS20MDSAllForms 32.pdf	Yes	Yes	Paper Only
Other-Form page 3			MDS20MDSAllForms 33.pdf	Yes	Yes	Paper Only
Other-Form page 4			MDS20MDSAllForms 34.pdf	Yes	Yes	Paper Only
Other-Form page 5			MDS20MDSAllForms 35.pdf	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 734

Number of Respondents for Small Entity: 353

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	187,170	187,170
Annual IC Time Burden (Hours)	132,011	132,011
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.