Initial and Terminal Administration of the Survey

Community Based Care Transitions Program (CCTP) Implementation and Monitoring

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Initial and Terminal Administration of the Survey	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:

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 %

	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

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.