Information Collection

(CMS-10310) - Initial Screening

IC 191849 under ICR 201001-0938-005 · OMB 0938-1081.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10310 (CMS-10310) - Initial Screening	Form and Instruction
CMS-10310 Attachment B2_Screening Form_Caregivers CMS-10310.Attachment B2_Screening Form_Caregivers_REV.doc	Form and Instruction
CMS-10310 Attachment B1_Screening Form_Consumers CMS-10310.Attachment B1_Screening Form_Consumers_REV.doc	Form and Instruction
CMS-10310 Attachment B3_Screening Form_Professionals_REV CMS-10310.Attachment B3_Screening Form_Professionals_REV.doc	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form?

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10310	Attachment B2_Screening Form_Caregivers	CMS-10310.Attachment B2_Screening Form_Caregivers_REV.doc	Yes	No	Fillable Fileable
Form and Instruction	CMS-10310	Attachment B1_Screening Form_Consumers	CMS-10310.Attachment B1_Screening Form_Consumers_REV.doc	Yes	No	Fillable Fileable
Form and Instruction	CMS-10310	Attachment B3_Screening Form_Professionals_REV	CMS-10310.Attachment B3_Screening Form_Professionals_REV.doc	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 80

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	80	80
Annual IC Time Burden (Hours)	7	7
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.