Information Collection

GenIC IC #2 - Cognitive Testing for Questions LGBT

IC 217196 under ICR 201504-0938-003 · OMB 0938-1275.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1275 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10549: GenIC#2 GenIC IC #2 - Cognitive Testing for Questions LGBT	Form and Instruction
CMS-10549: GenIC#2 GenIC#2 - MCBS Cognitive Testing LGBT Instruments GenIC#2. Attachments A - G.docx	Form and Instruction
GenIC#2 - MCBS Cognitive Testing LGBT Items 10 day letter.docx GenIC#2 - MCBS Cognitive Testing LGBT Items 10 day letter	IC Document

IC Title:

GenIC IC #2 - Cognitive Testing for Questions LGBT

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
Form and Instruction	CMS-10549: GenIC#2	GenIC#2 - MCBS Cognitive Testing LGBT Instruments	GenIC#2. Attachments A - G.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

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	100	100
Annual IC Time Burden (Hours)	55	55
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
GenIC#2 - MCBS Cognitive Testing LGBT Items 10 day letter	GenIC#2 - MCBS Cognitive Testing LGBT Items 10 day letter.docx	06/24/2015

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