Information Collection

Survey of Newly Eligible Medicare Beneficiaries

IC 43669 under ICR 200910-0938-017 · OMB 0938-0869.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10050 Survey of Newly Eligible Medicare Beneficiaries	Form and Instruction
CMS-10050 Survey of Newly Eligible Medicare Beneficiaries CMS-10050.Collection Instrument.doc	Form and Instruction

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
Form and Instruction	CMS-10050	Survey of Newly Eligible Medicare Beneficiaries	CMS-10050.Collection Instrument.doc		No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,200	-1,200	2,400
Annual IC Time Burden (Hours)	300	-500	800
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.