Information Collection

Medicaid Emergency Psychiatric Services Demonstration Evaluation - Facilities

IC 209878 under ICR 201312-0938-018 · OMB 0938-1225.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10487 Medicaid Emergency Psychiatric Services Demonstration Evaluation - Facilities	Form and Instruction
CMS-10487 Key Informant Interview Protocols Attachment_B.pdf	Form and Instruction
CMS-10487 Sampling Procedures for Medical Record Review Attachment_C.pdf	Form and Instruction
CMS-10487 Medical Record Review Tools Attachment_D.pdf	Form and Instruction
Crosswalks_508-cert_111813.pdf Crosswalk	IC Document
Attachment_F.pdf Conceptual Framework	IC Document
Attachment_G.pdf Technical Expert Panel	IC Document
Attachment_H.pdf Confidentiality Pledge	IC Document
Attachment_I.pdf Qualitative Data Coding Scheme	IC Document

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-10487	Key Informant Interview Protocols	Attachment_B.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10487	Sampling Procedures for Medical Record Review	Attachment_C.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10487	Medical Record Review Tools	Attachment_D.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 81

Number of Respondents for Small Entity: 27

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 10 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	972	972
Annual IC Time Burden (Hours)	1,458	1,458
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	Crosswalks_508-cert_111813.pdf	12/18/2013
Conceptual Framework	Attachment_F.pdf	12/23/2013
Technical Expert Panel	Attachment_G.pdf	12/23/2013
Confidentiality Pledge	Attachment_H.pdf	12/23/2013
Qualitative Data Coding Scheme	Attachment_I.pdf	12/23/2013

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