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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.