Information Collection

CAHPS Health Plan Health Literacy Module

IC 199359 under ICR 201109-0935-001 · OMB 0935-0189.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #1 CAHPS Health Plan Health Literacy Survey-- English CAHPS Health Plan Health Literacy Module	Form and Instruction
Form Form #2 CAHPS Health Plan Health Literacy Survey -Spanish CAHPS Health Plan Health Literacy Module	Form and Instruction
Form #1 CAHPS Health Plan Health Literacy Survey-- English Attachment B -- CAHPS Health Plan Health Literacy Survey -- English.docx	Form and Instruction
Form #2 CAHPS Health Plan Health Literacy Survey -Spanish Attachment C -- CAHPS Health Plan Health Literacy Survey -- Spanish.doc	Form and Instruction
Attachment D -- Pre-NotificationCoverLetters ReminderPCardLetterTelephone Script - English&Spanish.docx Attachment D -- Pre-NotificationCoverLetters ReminderPCardLetterTelephone Script - English&Spanish	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
Form and Instruction	Form #1				Yes	Yes	Paper Only
Form and Instruction	Form #2				Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000

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 Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	417	417
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment D -- Pre-NotificationCoverLetters ReminderPCardLetterTelephone Script - English&Spanish		09/20/2011

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

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