Information Collection

Initial and Terminal Administration of the Survey

IC 199899 under ICR 201110-0938-011 · OMB 0938-1167.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1167 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10403 Initial and Terminal Administration of the Survey	Form and Instruction
CMS-10403 CCTP - 1st Administration Appendix B CCTP 1st Admin Participant Exp Survey Draft (9-27-11 dab).docx	Form and Instruction
CMS-10403 CCTP - 2nd Administration Appendix B CCTP 2nd Admin Participant Exp Survey Draft (9-27-11 dab).docx	Form and Instruction
CMS-10403 CCTP -Spanish Version Appendix B CCTP items in Spanish.docx	Form and Instruction
CMS-10403 CCTP 1st Admin Participant Exp Survey CCTP 1st Admin Participant Exp Survey Draft (4-26-12 tk) Pilot Test.docx	Form and Instruction
CMS-10403 CCTP 2nd Admin CCTP 2nd Admin Participant Exp Survey Draft (3-12-12 glui) Pilot Test.docx	Form and Instruction

IC Title:

Initial and Terminal Administration of the Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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-10403	CCTP - 1st Administration	Appendix B CCTP 1st Admin Participant Exp Survey Draft (9-27-11 dab).docx	No	No	Paper Only
Form and Instruction	CMS-10403	CCTP - 2nd Administration	Appendix B CCTP 2nd Admin Participant Exp Survey Draft (9-27-11 dab).docx	No	No	Paper Only
Form and Instruction	CMS-10403	CCTP -Spanish Version	Appendix B CCTP items in Spanish.docx	No	No	Paper Only
Form and Instruction	CMS-10403	CCTP 2nd Admin	CCTP 2nd Admin Participant Exp Survey Draft (3-12-12 glui) Pilot Test.docx	No		Paper Only
Form and Instruction	CMS-10403	CCTP 1st Admin Participant Exp Survey	CCTP 1st Admin Participant Exp Survey Draft (4-26-12 tk) Pilot Test.docx	No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,900

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	1,900	1,900
Annual IC Time Burden (Hours)	475	475
Annual IC Cost Burden (Dollars)	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.