Information Collection

State Burden

IC 209182 under ICR 201311-0938-001 · OMB 0938-1239.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1239 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10493 State Burden	Form and Instruction
CMS-10493 Phone Script - CAHPS 5.0H Adult Questionnaire (Medicaid) CMSAdultMedicaidCAHPSEnglishCATI_script 112513_clean.docx	Form and Instruction
CMS-10493 CAHPS 5.0H Adult Questionnaire (Medicaid) 11_25_2013_CAHPS_Adult_MEDICAID_Mockup.pdf	Form and Instruction

IC Title:

State Burden

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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-10493	Phone Script - CAHPS 5.0H Adult Questionnaire (Medicaid)	CMSAdultMedicaidCAHPSEnglishCATI_script 112513_clean.docx		No	No	Printable Only
Form and Instruction	CMS-10493	CAHPS 5.0H Adult Questionnaire (Medicaid)	11_25_2013_CAHPS_Adult_MEDICAID_Mockup.pdf		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	2,040	2,040
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.