OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

IC 8171 under ICR 201008-0938-025 · OMB 0938-0568.

Documents and Forms
Document Name
Document Type
Other-Facility Screening Interview S
Other-MCBS Facility Round 55 Instrum
Other-English Specifications
Other-English Specifications
Other-English Specifications
Other-English Specifications
Other-English Sepcifications
Other-English Specifications
Other-English Specifications
Other-English Specifications
Other-English Specifications
Other-English Specifications
Other-English Specifications
Other-English Specifications
Other-English Specifications
Other-English Specifications
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-Questionnaire
Other-English Rosters
Other-English Roster
Other-English Rosters
Other-English Rosters
Other-English Rosters
Other-English Rosters
Other-English Rosters
Other-English Rosters
Other-English Rosters
Other-English Rosters
Other-English Rosters
Other-English Rosters
Other-English Rosters
Other-Spanish Questionnaire
Other-Spanish Questionnaire
Other-Spanish Questionnaire
Other-Spanish Questionnaire
Other-Spanish Questionnaire
Other-Spanish Questionnaire
Other-Spanish Questionnaire
Other-Spanish Questionnaire
Other-Spanish Questionnaire
Other-Spanish Version
Other-Spanish Version
Other-Spanish Version
Other-Spanish Version
Other-Spanish Version
Other-Spanish Version
Other-Spanish Version
Other-Spanish Version
Other-Spanish Version
Other-Spanish Version
Other-Spanish Version
Other-Spanish Version
Other-Spanish Version
Other-Spanish Version
Other-Spanish Version
Other-Spanish Version
Other-Spanish Version
Other-Spanish Version
Other-Spanish Version
Other-English Show Cards
Other-Spanish Show Cards
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Spanish Version Attachment 4 Spanish version part IV-AAV Round 55.pdf Yes Yes Printable Only
Other-Facility Screening Interview Script for Meeting with Facility Administrators attachment 05.zip Yes Yes Printable Only
Other-MCBS Facility Round 55 Instrument attachment 06.zip Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by Section DU_04.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by Section CPS_07.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by Section DI_04.01.0002.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by Section DM_05.01.0000.pdf Yes Yes Printable Only
Other-English Rosters Attachment 4 English RostersPMRoster04010000PopUpVars.pdf Yes Yes Printable Only
Other-Spanish Questionnaire Attachment 4 Spanish QuestionnaireOP Round 55.pdf Yes Yes Printable Only
Other-Spanish Version Attachment 4 Spanish Version Part IV-ACPS Round 55.pdf Yes Yes Printable Only
Other-Spanish Version Attachment 4 Spanish Version Part IV-ADM Round 55.pdf Yes Yes Printable Only
Other-Spanish Version Attachment 4 Spanish Version Part IV-AEND Round 55.pdf Yes Yes Printable Only
Other-English Specifications Attachment 4 English Specifications ATTACHMENTHI2.pdf Yes Yes Printable Only
Other-English Rosters Attachment 4 English Rosters ConditionRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-English Roster Attachment 4 English Rosters DMRoster0401_0000PopUpVars.pdf Yes Yes Printable Only
Other-English Specifications Attachment 4 English Questionnaire Layout.pdf Yes Yes Printable Only
Other-English Rosters Attachment 4 English Rosters PlanRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 English Questionnaire Comprehensive Format Section by SectionIP_05.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 English Questionnaire Comprehensive Format Section by SectionIP_05.01.0000.pdf Yes Yes Printable Only
Other-English Rosters Attachment 4 English RostersStatementChargeBundleRoster0501_0000PopUpVars.pdf Yes Yes Printable Only
Other-Spanish Version Attachment 4 Spanish Version Part IV-AIP Round 55.pdf Yes Yes Printable Only
Other-Spanish Version Attachment 4 Spanish Version Part IV-AMC Round 55.pdf Yes Yes Printable Only
Other-English Specifications Attachment 4 English Specifications - ATTACHMENTHI1.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by Section CE_04.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by Section CL_07.01.0000.pdf Yes Yes Printable Only
Other-Spanish Questionnaire Attachment 4 Spanish QuestionnairePS Round 55.pdf Yes Yes Printable Only
Other-Spanish Questionnaire Attachment 4 Spanish QuestionniareUSRound55.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by Section AC_04.01.0001.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by Section AV_05.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by Section HA_05.01.0003.pdf Yes Yes Printable Only
Other-Spanish Version Attachment 4 Spanish Version Part IV-AHI & HIS Round 55.pdf Yes Yes Printable Only
Other-English Rosters Attachment 4 English Rosters EventRosterBeginDateRV0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-English Rosters Attachment 4 English Rosters PersonRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-English Rosters Attachment 4 English RostersStatementEventRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-English Rosters Attachment 4 English RostersStatementOMEditRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-English Rosters Attachment 4 English RostersStatementEventEditRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-English Rosters Attachment 4 English RostersSOPRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-Spanish Questionnaire Attachment 4 Spanish QuestionaireSCRound55.pdf Yes Yes Printable Only
Other-Spanish Questionnaire Attachment 4 Spanish Questionnaire MP Round 55.pdf Yes Yes Printable Only
Other-Spanish Questionnaire Attachment 4 Spanish QuestionnaireNS Round 55.pdf Yes Yes Printable Only
Other-Spanish Questionnaire Attachment 4 Spanish QuestionnaireOM Round 55.pdf Yes Yes Printable Only
Other-Spanish Questionnaire Attachment 4 Spanish QuestionnairePM & PMS Round 55.pdf Yes Yes Printable Only
Other-Spanish Version Attachment 4 Spanish Version Part IV-AHH & HHS Round 55.pdf Yes Yes Printable Only
Other-Spanish Version Attachment 4 Spanish Version IV-A AC Round 55.pdf Yes Yes Printable Only
Other-Spanish Version Attachment 4 Spanish Version Part IV-ACL Round 55.pdf Yes Yes Printable Only
Other-Spanish Version Attachment 4 spanish Version Part IV-AHF Round 55.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by Section HH_05.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by Section HHS_04.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by SectionHI_05.01.0001.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by Section HF_05.01.0008.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by Section HIS_05.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by SectionER_04.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 English Questionnaire Comprehensive Format by SectionPM_06.01.0001.pdf Yes Yes Printable Only
Other-English Rosters Attachment 4 English RostersProviderRoster0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by Section BackgroundVariables_07.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by Section ENS_07.01.0001.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format section by Section EX_03.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by SectionPMS_05.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by SectionMP_05.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by SectionIU_05.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by SectionIRQ_05.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by SectionIP_05.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by SectionIN_05.01.0001.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by SectionIA_05.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 English Questionnaire Comprehensive Formate Section by SectionPMS_05.01.0000.pdf Yes Yes Printable Only
Other-Spanish Version Attachment 4 Spanish Version Part IV-AEN & ENS Round 55.pdf Yes Yes Printable Only
Other-Spanish Version Attachment 4 Spanish Version Part IV-AER Round 55.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 English Questionnaire Comprehensive Format by SectionRX_05.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 English Questionnaire Comprehensive Format by SectionST_05.01.0001.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 English Questionnaire Comprehensive Format by SectionUS_05.01.0001.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by SectionPA_04.01.0001.pdf Yes Yes Printable Only
Other-English Specifications Attachment 4 English Questionnaire Condensed Format.pdf Yes Yes Printable Only
Other-Spanish Version Attachment 4 Spanish Version part IV-ADI Round 52.pdf Yes Yes Printable Only
Other-Spanish Version Attachment 4 Spanish Version Part IV-ADU Round 55.pdf Yes Yes Printable Only
Other-Spanish Version Attachment 4 Spanish Version Part IV-AHA Round 55.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 English Questionnaire comprehensive Format Section by SectionIA_05.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 English Questionnaire Comprehensive Format Section by SectionHI_05.01.0001.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 English Questionnaire Comprehensive Format Section by SectionMP_05.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionnaire Comprehensive Format Section by SectionOP_05.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 English Questionnaire Comprehensive Format Section by SectionIN_05.01.0001.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 English Questionnaire Comprehensive Format Section by SectionOM_05.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 English Questionnaire Comprehensive Format Section by SectionOP_05.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 English Questionnaire Comprehensive Format Section by SectionPA_04.01.0001.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 English Questionaire Comprehensive Format Section by SectionIRQ_05.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 English Questionnaire Comprehensive Format Section by Section KN_02.01.0003.pdf Yes Yes Printable Only
Other-English Sepcifications Attachment 4 English Specifications GeneralSpecificationsDatabase07010001.pdf Yes Yes Printable Only
Other-English Specifications Attachment 4 English Specifications GeneralSpecificationsDates07010001.pdf Yes Yes Printable Only
Other-English Specifications Attachment 4 English Specifications GeneralSpecificationsDefaultSpecification07010001.pdf Yes Yes Printable Only
Other-Spanish Questionnaire Attachment 4 Spanish QuestionnaireSTRound55.pdf Yes Yes Printable Only
Other-English Rosters Attachment 4 English Rosters EventRosterBeginDate0301_0000PopUpVars.pdf Yes Yes Printable Only
Other-Spanish Version Attachment 4 Spanish version Part IV-AHISMC & HIMC Round 55.pdf Yes Yes Printable Only
Other-Spanish Version Attachment 4 Spanish Version Part IV-AHIST & HIT Round 55.pdf Yes Yes Printable Only
Other-Spanish Version Attachment 4 Spanish Version Part IV-AIN & INS Round 55.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 English Questionnaire Comprehensive Format Section by Section NS_07.01.0003.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 Questionaire Comprehensive Format Section by Section END_04.01.0000.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 English Questionnaire Conprehensive Format by SectionSC_05.01.0003.pdf Yes Yes Printable Only
Other-Questionnaire Attachment 4 English Questionnaire Comprehensive Format by SectionPS_04.01.0000.pdf Yes Yes Printable Only
Other-English Specifications Attachment 4 English Specifications GeneralSpecificationsAttachments07010001.pdf Yes Yes Printable Only
Other-English Specifications Attachment 4 English Specifications GeneralSpecifications07010001.pdf Yes Yes Printable Only
Other-English Specifications Attachment 4 English Specifications GeneralSpecificationsGlobalDisplays07010001.pdf Yes Yes Printable Only
Other-English Specifications Attachment 4 English Specifications GeneralSpecificationsQuestionnaireFlow07010001.pdf Yes Yes Printable Only
Other-English Specifications Attachment 4 English Specifications GeneralSpecificationsScreenTypes07010001.pdf Yes Yes Printable Only
Other-English Specifications Attachment 4 English Specifications GeneralSpecificationsSectionOverview07010001.pdf Yes Yes Printable Only
Other-English Specifications Attachment 4 English Specifications MCBSWVSTechnicalNotes0501_0000.pdf Yes Yes Printable Only
Other-English Show Cards Current MCBS English Showcards.pdf Yes Yes Printable Only
Other-Spanish Show Cards Current MCBS Spanish Showcards.pdf Yes Yes Printable Only

Health Health Care Services

 

16,217 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 48,650 0 2,450 0 0 46,200
Annual IC Time Burden (Hours) 57,062 0 10,092 0 0 46,970
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
attachment 01 attachment 01.zip 08/25/2010
attachment 02 attachment 02.zip 08/25/2010
attachment 03 attachment 03.zip 08/25/2010
Attachments TOC Attachments TOC.pdf 08/25/2010
attachment 07 attachment 07.zip 08/25/2010
attachment 08 attachment 08.zip 08/25/2010
attachment 09 attachment 09.zip 08/25/2010
attachment 10 attachment 10.zip 08/25/2010
attachment 11 attachment 11.zip 08/25/2010
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.