Home and Community-Based Services (HCBS) Experience Survey

Home and Community-Based Services (HCBS) Experience Survey

OMB: 0938-1186

IC ID: 203499

Information Collection (IC) Details

View Information Collection (IC)

Home and Community-Based Services (HCBS) Experience Survey
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

18,000 0
   
Individuals or Households
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 18,000 18,000 0 0 0 0
Annual IC Time Burden (Hours) 9,000 9,000 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

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