Information Collection

Survey

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

Documents and Forms

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

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10399	Yes	No	Fillable Fileable
Form and Instruction	CMS-10399	Yes	No	Fillable Fileable
Form and Instruction	CMS-10399	Yes	No	Fillable Fileable
Form and Instruction	CMS-10399	Yes	No	Fillable Fileable
Form and Instruction	CMS-10399	Yes	No	Fillable Fileable
Form and Instruction	CMS-10399	Yes	No	Fillable Fileable
Form and Instruction	CMS-10399	Yes	No	Fillable Fileable
Form and Instruction	CMS-10399	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	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

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.

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