Home and Community-Based Services (HCBS) Experience Survey

Home and Community-Based Services (HCBS) Experience Survey

OMB: 0938-1186

IC ID: 203499

Documents and Forms
Document Name
Document Type
Form and Instruction
Instruction
Other-Cover Letter (English)
Other-Cover Letter (Spanish)
Form
Form
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

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

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10389 Survey Instruments Attachement B_Survey_Instruments_9_18_12.docx Yes Yes Fillable Printable
Form CMS-10389 Consent Form (Spanish) Consent form_Spanish.docx Yes Yes Fillable Printable
Form CMS-10389 Consent Form (English) Consent form_9_12_12_English.docx Yes Yes Fillable Printable
Instruction Attachment C Contact Script_revised_clean.docx Yes No Fillable Printable
Other-Cover Letter (English) Field test cover letter template_English .doc Yes Yes Fillable Printable
Other-Cover Letter (Spanish) Field test cover letter template_Spanish.doc Yes Yes Fillable Printable

Health Health Care Services

 

18,000 0
   
Individuals or Households
 
   100 %

  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 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

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