Information Collection

Medicare Beneficiares

IC 192996 under ICR 201005-0990-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-PHRC-Appx E questionnaire.docx	Other-Questionaire
0990-PHRC-Appx G intro phone script.doc	Other-Telephone Script
0990-PHRC- Appx D1 DRAFT patient letter.doc 0990-PHRC- Appx D1 DRAFT patient letter	IC Document
0990-PHRC-Appx F draft postcard.doc 0990-PHRC-Appx F draft postcard	IC Document
0990-PHRC- Appx D2 DRAFT patient FOLLOWUP Letter.doc 0990-PHRC- Appx D2 DRAFT patient FOLLOWUP Letter	IC Document
0990-PHRC-Appx A ARRA legislation.pdf 0990-PHRC-Appx A ARRA legislation	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Questionaire			0990-PHRC-Appx E questionnaire.docx		No	No	Paper Only
Other-Telephone Script			0990-PHRC-Appx G intro phone script.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	208	208
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
0990-PHRC- Appx D1 DRAFT patient letter	0990-PHRC- Appx D1 DRAFT patient letter.doc	04/19/2010
0990-PHRC-Appx F draft postcard	0990-PHRC-Appx F draft postcard.doc	04/19/2010
0990-PHRC- Appx D2 DRAFT patient FOLLOWUP Letter	0990-PHRC- Appx D2 DRAFT patient FOLLOWUP Letter.doc	04/19/2010
0990-PHRC-Appx A ARRA legislation	0990-PHRC-Appx A ARRA legislation.pdf	04/19/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.