Initial and Terminal Administration of the Survey

Community Based Care Transitions Program (CCTP) Implementation and Monitoring

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.