Information Collection

Statistical Data - Households

IC 46618 under ICR 201004-0938-004 · OMB 0938-1015.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10197 Statistical Data - Households	Form and Instruction
CMS-10197 CMS-10197 AppendixD-InfConsentFormsScripts CMS-10197 AppendixD-InfConsentFormsScripts11_6_508ready.pdf	Form and Instruction
CMS-10197 CMS-10197 Appendix B Statistical Instruments CMS-10197 AppendixBStatisticalInstruments32610.pdf	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-10197	CMS-10197 AppendixD-InfConsentFormsScripts	CMS-10197 AppendixD-InfConsentFormsScripts11_6_508ready.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10197	CMS-10197 Appendix B Statistical Instruments	CMS-10197 AppendixBStatisticalInstruments32610.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Master Demonstration, Evaluation and Research Studies for ORDI

FR Citation: 72 FR 19705

Number of Respondents: 8,336

Number of Respondents for Small Entity: 8,336

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 30 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	8,336	7,671	665
Annual IC Time Burden (Hours)	4,168	3,617	551
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.