Information Collection

For-Profit PACE Study

IC 203502 under ICR 201207-0938-006 · OMB 0938-1180.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.