OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Medicare Plan Finder Experiment

IC 205057 under ICR 201212-0938-003 · OMB 0938-1201.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form CMS-10441
Medicare Plan Finder Experiment		 Form and Instruction
CMS-10441 Attachment_E-a
Attachment_E-a.pdf 		Form and Instruction
CMS-10441 Attachment J - post survey conditions 3 and 4 - 100112
Attachment J - post survey conditions 3 and 4 - 100112.pdf 		Form and Instruction
CMS-10441 Attachment L - post survey conditions 7 and 8
Attachment L - post survey conditions 7 and 8 - 100112.pdf 		Form and Instruction
CMS-10441 Attachment N - post survey conditions 11 and 12
Attachment N - post survey conditions 11 and 12 - 100112.pdf 		Form and Instruction
CMS-10441 Attachment_B-a
Attachment_B-a.pdf 		Form and Instruction
CMS-10441 Attachment_C-a
Attachment_C-a.pdf 		Form and Instruction
CMS-10441 Attachment_A-a
Attachment_A-a.pdf 		Form and Instruction
CMS-10441 Attachment_D-a
Attachment_D-a.pdf 		Form and Instruction
CMS-10441 Attachment_F-a
Attachment_F-a.pdf 		Form and Instruction
CMS-10441 Attachment_G-a
Attachment_G-a.pdf 		Form and Instruction
CMS-10441 Attachment H - pre-exposure survey 100112
Attachment H - pre-exposure survey 100112.pdf 		Form and Instruction
CMS-10441 Attachment_I-post_survey_conditions_1_and_2
Attachment_I-post_survey_conditions_1_and_2_508_083112.pdf 		Form and Instruction
CMS-10441 Attachment K - post survey conditions 5 and 6
Attachment K - post survey conditions 5 and 6 - 100112.pdf 		Form and Instruction
CMS-10441 Attachment M - post survey conditions 9 and 10
Attachment M - post survey conditions 9 and 10 100112.pdf 		Form and Instruction
CMS-10441 Attachment O - post survey conditions 13 and 14
Attachment O - post survey conditions 13 and 14 - 100112.pdf 		Form and Instruction
CMS-10441 Attachment P - post survey conditions 15 and 16
Attachment P - post survey conditions 15 and 16 - 100112.pdf 		Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

layout table

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-10441 Attachment_E-a Attachment_E-a.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10441 Attachment J - post survey conditions 3 and 4 - 100112 Attachment J - post survey conditions 3 and 4 - 100112.pdf No Yes Fillable Fileable
Form and Instruction CMS-10441 Attachment L - post survey conditions 7 and 8 Attachment L - post survey conditions 7 and 8 - 100112.pdf No No Fillable Fileable
Form and Instruction CMS-10441 Attachment N - post survey conditions 11 and 12 Attachment N - post survey conditions 11 and 12 - 100112.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10441 Attachment_B-a Attachment_B-a.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10441 Attachment_C-a Attachment_C-a.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10441 Attachment_A-a Attachment_A-a.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10441 Attachment_D-a Attachment_D-a.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10441 Attachment_F-a Attachment_F-a.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10441 Attachment_G-a Attachment_G-a.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10441 Attachment H - pre-exposure survey 100112 Attachment H - pre-exposure survey 100112.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10441 Attachment_I-post_survey_conditions_1_and_2 Attachment_I-post_survey_conditions_1_and_2_508_083112.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10441 Attachment K - post survey conditions 5 and 6 Attachment K - post survey conditions 5 and 6 - 100112.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10441 Attachment M - post survey conditions 9 and 10 Attachment M - post survey conditions 9 and 10 100112.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10441 Attachment O - post survey conditions 13 and 14 Attachment O - post survey conditions 13 and 14 - 100112.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10441 Attachment P - post survey conditions 15 and 16 Attachment P - post survey conditions 15 and 16 - 100112.pdf Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved 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 600 0 600 0 0 0
Annual IC Time Burden (Hours) 252 0 252 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
No associated records found
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.