Information Collection

Preventive Services in Medicaid Survey

IC 212468 under ICR 201407-0938-015 · OMB 0938-1260.

Documents and Forms

Document Name Document Type
Form CMS-10521 Preventive Services in Medicaid Survey Form and Instruction
CMS-10521 Preventive Services in Medicaid Survey F-Preventive Services in Medicaid Survey [rev 7-25-2014 by OSORA PRA].docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Preventive Services in Medicaid Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10521	Preventive Services in Medicaid Survey	F-Preventive Services in Medicaid Survey [rev 7-25-2014 by OSORA PRA].docx		Yes	Yes	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 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	128	128
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.