Information Collection

MAPCP - Individuals Representing Community Health Teams and Networks

IC 206742 under ICR 201304-0938-009 · OMB 0938-1211.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10436 MAPCP - Individuals Representing Community Health Teams and Networks	Form and Instruction
CMS-10436 Protocol - Community Health Teams Protocol_CHT_2-13-13.pdf	Form and Instruction
CMS-10436 Protocol - Networks protocol_networks_2-13-13.pdf	Form and Instruction
CMS-10436 Protocol - SASH Protocol_SASH_2-13-13.pdf	Form and Instruction

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10436	Protocol - Community Health Teams	Protocol_CHT_2-13-13.pdf	No	No	Paper Only
Form and Instruction	CMS-10436	Protocol - Networks	protocol_networks_2-13-13.pdf	No	No	Paper Only
Form and Instruction	CMS-10436	Protocol - SASH	Protocol_SASH_2-13-13.pdf	No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 24

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	24	24
Annual IC Time Burden (Hours)	18	18
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.