Information Collection

GenIC #49 Model Online Eligibility Results: Consumer Testing Interviews

IC 221897 under ICR 201410-0938-016 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ModelEligibilityResultsPage_Scens 5+8a_v11rc_060316.pdf	Other-Model Online Eligibility Resul
CMS-10398 #49 Testing Protocol CMS_ModelOnlineEligibilityResultsPage_Protocol_061016.docx	Form and Instruction
GenIC #49 - Eligibility Results, Consumer Testing Interviews [rev 06-12-2016 by OSORA PRA].docx GenIC #49 - Model Online Eligibility Results: Consumer Testing Interviews	IC Document

IC Title:

GenIC #49 Model Online Eligibility Results: Consumer Testing Interviews

Agency IC Tracking Number:

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
Other-Model Online Eligibility Results Page			ModelEligibilityResultsPage_Scens 5+8a_v11rc_060316.pdf		Yes	No	Printable Only
Form and Instruction	CMS-10398 #49	Testing Protocol	CMS_ModelOnlineEligibilityResultsPage_Protocol_061016.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 48

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	48	48
Annual IC Time Burden (Hours)	48	48
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
GenIC #49 - Model Online Eligibility Results: Consumer Testing Interviews	GenIC #49 - Eligibility Results, Consumer Testing Interviews [rev 06-12-2016 by OSORA PRA].docx	06/12/2016

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