Information Collection

Survey

IC 202089 under ICR 201204-0938-005 · OMB 0938-1182.

Documents and Forms

Document Name Document Type
Form CMS-10399 Survey Form and Instruction
CMS-10399 Appendix B PROVIDERS TBS Appendix B PROVIDERS TBS.pdf Form and Instruction
CMS-10399 Appendix A BENEFICIARY TBS Appendix A BENEFICIARY TBS.pdf Form and Instruction
CMS-10399 Appendix C Beneficiary Interview Protocol Appendix C Beneficiary Interview Protocol.pdf Form and Instruction
CMS-10399 Appendix F Providers Interview Protocol Appendix F Providers Interview Protocol.pdf Form and Instruction
CMS-10399 Appendix D Beneficiaries and Family Members Demographic Appendix D Beneficiaries and Family Members Demographic Survey.pdf Form and Instruction
CMS-10399 Appendix E Beneficiaries and Family Members Focus Group Appendix E Beneficiaries and Family Members Focus Group Protocol.pdf Form and Instruction
CMS-10399 Appendix G CMS Consent Forms Appendix G CMS Consent Forms.pdf Form and Instruction
CMS-10399 Appendix H1 and H2 HEALTH CARE PROVIDER RECRUITMENT LETT Appendix H1 and H2 HEALTH CARE PROVIDER RECRUITMENT LETTERS.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

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-10399	Appendix B PROVIDERS TBS	Appendix B PROVIDERS TBS.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10399	Appendix A BENEFICIARY TBS	Appendix A BENEFICIARY TBS.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10399	Appendix C Beneficiary Interview Protocol	Appendix C Beneficiary Interview Protocol.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10399	Appendix F Providers Interview Protocol	Appendix F Providers Interview Protocol.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10399	Appendix D Beneficiaries and Family Members Demographic Survey	Appendix D Beneficiaries and Family Members Demographic Survey.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10399	Appendix E Beneficiaries and Family Members Focus Group Protocol	Appendix E Beneficiaries and Family Members Focus Group Protocol.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10399	Appendix G CMS Consent Forms	Appendix G CMS Consent Forms.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10399	Appendix H1 and H2 HEALTH CARE PROVIDER RECRUITMENT LETTERS	Appendix H1 and H2 HEALTH CARE PROVIDER RECRUITMENT LETTERS.pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,418	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	3,418	3,418
Annual IC Time Burden (Hours)	2,544	2,544
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.