Information Collection

Home and Community-Based Services (HCBS) Experience Survey

IC 203499 under ICR 201207-0938-005 · OMB 0938-1186.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1186 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10389 Home and Community-Based Services (HCBS) Experience Survey Form and Instruction
Attachment C Contact Script_revised_clean.docx Instruction
Field test cover letter template_English.doc Other-Letter (English)
Field test cover letter template_Spanish.doc Other-Letter (Spanish)
CMS-10389 Attachment B Survey Instruments Attachement B_Survey_Instruments_9_18_12.docx Form and Instruction
CMS-10389 Consent Form English Consent form_9_12_12_English.docx Form
CMS-10389 Consent Form Spanish Consent form_Spanish.docx Form
Attachment A Legal Justification (11 Mar 12).pdf Attachment A - Legal Justification IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Home and Community-Based Services (HCBS) Experience 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-10389	Attachment B Survey Instruments	Attachement B_Survey_Instruments_9_18_12.docx	Yes	Yes	Fillable Printable
Instruction			Attachment C Contact Script_revised_clean.docx	Yes	Yes	Fillable Printable
Form	CMS-10389	Consent Form Spanish	Consent form_Spanish.docx	Yes	Yes	Fillable Printable
Other-Letter (English)			Field test cover letter template_English.doc	Yes	Yes	Fillable Printable
Other-Letter (Spanish)			Field test cover letter template_Spanish.doc	Yes	Yes	Fillable Printable
Form	CMS-10389	Consent Form English	Consent form_9_12_12_English.docx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 18,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	18,000	18,000
Annual IC Time Burden (Hours)	9,000	9,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment A - Legal Justification	Attachment A Legal Justification (11 Mar 12).pdf	07/26/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.