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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.