Information Collection

Initial and Terminal Administration of the Survey

IC 199899 under ICR 201408-0938-002 · OMB 0938-1167.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10403 Initial and Terminal Administration of the Survey	Form and Instruction
CMS-10403 CCTP -Spanish Version Appendix B CCTP items in Spanish.docx	Form and Instruction
CMS-10403 CCTP 1st Admin Participant Exp Suvey Revised CCTP 1st Admin Participant Exp Survey Revised 07_15_2014.docx	Form and Instruction
CMs-10403 CCTP 2nd Admin Participant Exp Survey Revised CCTP 2nd Admin Participant Exp Survey_Revised 07.15.2014.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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-10403	CCTP -Spanish Version	Appendix B CCTP items in Spanish.docx	No	No	Paper Only
Form and Instruction	CMS-10403	CCTP 1st Admin Participant Exp Suvey Revised	CCTP 1st Admin Participant Exp Survey Revised 07_15_2014.docx	No		Paper Only
Form and Instruction	CMs-10403	CCTP 2nd Admin Participant Exp Survey Revised	CCTP 2nd Admin Participant Exp Survey_Revised 07.15.2014.docx	No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 216,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	432,000	432,000
Annual IC Time Burden (Hours)	54,000	54,000
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.