Information Collection

National Readiness Survey

IC 211401 under ICR 201404-0938-008 · OMB 0938-1252.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10509 National Readiness Survey	Form and Instruction
CMS-10509 National Survey of Medicare Beneficiaries OMB_Wellness_Eval_Part_A_Attachment_2_National_Surveys_08122014_clean.docx	Form and Instruction
OMB_Draft_Wellness_Eval_Part_A_Attachment_1_Legal_Authority_03112014.pdf Legal Authority	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-10509	National Survey of Medicare Beneficiaries	OMB_Wellness_Eval_Part_A_Attachment_2_National_Surveys_08122014_clean.docx		No		Fillable Fileable

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: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	18,000	18,000
Annual IC Time Burden (Hours)	8,529	8,529
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Legal Authority	OMB_Draft_Wellness_Eval_Part_A_Attachment_1_Legal_Authority_03112014.pdf	04/28/2014

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