Information Collection

Home and Community-Based Services (HCBS) Experience Survey

IC 203499 under ICR 201302-0938-001 · OMB 0938-1186.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10389 Home and Community-Based Services (HCBS) Experience Survey	Form and Instruction
Attachment C Contact Script_revised_clean.docx	Instruction
Field test cover letter template_English .doc	Other-Cover Letter (English)
Field test cover letter template_Spanish.doc	Other-Cover Letter (Spanish)
CMS-10389 Consent Form (Spanish) Consent form_Spanish.docx	Form
CMS-10389 Consent Form (English) Consent form_9_12_12_English.docx	Form
CMS-10389 Survey Instruments Attachement B_Survey_Instruments_9_18_12.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 18,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	18,000	18,000
Annual IC Time Burden (Hours)	9,000	9,000
Annual IC Cost Burden (Dollars)	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.