Information Collection

Medicaid Emergency Psychiatric Services Demonstration Evaluation - states

IC 209880 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 - states	Form and Instruction
CMS-10487 Key Informant Interview Protocols Attachment_B.pdf	Form and Instruction
MEPD IRB Section 9 Rationale.pdf MEPD IRB Section 9 Rationale	IC Document
MEPD Protocols Medical Record Review Consent.pdf MEPD Protocols Medical Record Review Consent	IC Document
MEPD RequestFormExemption.pdf MEPD RequestFormExemption	IC Document
NEIRB_exemption_granted_112213.pdf NEIRB_exemption_granted_112213	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10487	Key Informant Interview Protocols	Attachment_B.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	108	108
Annual IC Time Burden (Hours)	588	588
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
MEPD IRB Section 9 Rationale	MEPD IRB Section 9 Rationale.pdf	02/27/2014
MEPD Protocols Medical Record Review Consent	MEPD Protocols Medical Record Review Consent.pdf	02/27/2014
MEPD RequestFormExemption	MEPD RequestFormExemption.pdf	02/27/2014
NEIRB_exemption_granted_112213	NEIRB_exemption_granted_112213.pdf	02/27/2014

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