Information Collection

Inital Screening Round 2 (Cognitive Interviews)

IC 199205 under ICR 201107-0938-003 · OMB 0938-1143.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10360 Inital Screening Round 2 (Cognitive Interviews)	Form and Instruction
Mini Part A for first IC_061711.pdf	Instruction
CMS-10360 Screener_Healthcare Patient Consumers Screener_Healthcare Patient Consumers.pdf	Form and Instruction
CMS-10360 Consent Form Consent Form.pdf	Form and Instruction
CMS-10360 Screener_Informal Family Caregivers Screener_Informal Family Caregivers.pdf	Form and Instruction
CMS-10360 HAI_HAC_MockUps HAI_HAC_MockUps.pdf	Form
CMS-10360 ED throughput ED throughput.pdf	Form

IC Title:

Agency IC Tracking Number:

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-10360	Screener_Healthcare Patient Consumers	Screener_Healthcare Patient Consumers.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10360	Consent Form	Consent Form.pdf	Yes	No	Fillable Fileable
Instruction			Mini Part A for first IC_061711.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10360	Screener_Informal Family Caregivers	Screener_Informal Family Caregivers.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10360	HAI_HAC_MockUps	HAI_HAC_MockUps.pdf	Yes	No	Fillable Fileable
Form	CMS-10360	ED throughput	ED throughput.pdf	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

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 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	40	0	0	0	0	0
Annual IC Time Burden (Hours)	3	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	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.