Information Collection

Preventive Services in Medicaid Survey

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

Documents and Forms

Documents and forms in this information collection
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

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-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 %

table that charts list of burden
	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

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.