Survey

Analysis of Transportation Barriers to Utilization of Medicare Services by American Indian and Alaska Native Medicare Beneficiaries

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

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.