Information Collection

(CMS-10310) - Patient and Caregiver Interviews

IC 191851 under ICR 201001-0938-005 · OMB 0938-1081.

Documents and Forms

Document Name Document Type
Form CMS-10310 (CMS-10310) - Patient and Caregiver Interviews Form and Instruction
CMS-10310 Attachment C1 - Cogntive Interview Guide Consumers Careg CMS-10310.Attachment C1_Cogntive Interview Guide_Consumers_Caregivers-CLEAN-2-3-10.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	(CMS-10310) - Patient and Caregiver Interviews	Agency IC Tracking Number:

Is this a Common Form?		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
Form and Instruction	CMS-10310	Attachment C1 - Cogntive Interview Guide Consumers Caregivers	CMS-10310.Attachment C1_Cogntive Interview Guide_Consumers_Caregivers-CLEAN-2-3-10.doc		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	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	20	20
Annual IC Time Burden (Hours)	30	30
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.