For-Profit PACE Study

Documents and Forms

Document Name Document Type
Form CMS-10427 For-Profit PACE Study Form and Instruction
CMS-10427 PACE Survey 06965_PACE_OMB_APP_B_06_20_12.docx Form and Instruction
Crosswalk CMS-10427.doc Crosswalk CMS-10427 IC Document
CMS-10427 Appendix A 10 24 12.docx CMS-10427 Appendix A 10 24 12 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	For-Profit PACE Study	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10427	PACE Survey	06965_PACE_OMB_APP_B_06_20_12.docx		No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 813	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	813	813
Annual IC Time Burden (Hours)	447	447
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk CMS-10427	Crosswalk CMS-10427.doc	07/18/2012
CMS-10427 Appendix A 10 24 12	CMS-10427 Appendix A 10 24 12.docx	10/25/2012

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