Information Collection

Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

IC 8171 under ICR 201506-0938-011 · OMB 0938-0568.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0568 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-P-0015A Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form and Instruction
CMS-P-0015A Attachment 5 - Facility Screener Facility Screener May 2012.pdf	Form and Instruction
CMS-P0015A Attachment 6 - MCBS Faclility Round 64 Instruments attachment 6.zip	Form and Instruction
CMS-P0015A Attachment 8 - Verification Re-interview ValidationInterviewCommunityComponent.zip	Form and Instruction
CMS-P0015A MCBS Household Round 67 Instruments Attachment 4.zip	Form and Instruction
CMS-P0015A General Specifications Screen Types_19.01.0001 General Specifications Screen Types_19.01.0001.pdf	Form and Instruction
CMS-P0015A General Specifications Spanish Text_19.01.001 General Specifications Spanish Text_19.01.001.pdf	Form and Instruction
CMS-P0015A Spanish Folder General Specifications Spanish Text_19.01 General Specifications Spanish Text_19.01.001.pdf	Form and Instruction
CMS-P0015A English Showcards HI-Eng HI-Eng.pdf	Form and Instruction
CMS-P0015A Spanish Showcars KN-Sp KN-Sp.pdf	Form and Instruction
CMS-P0015A English Section by Section CPS_16.01.0002 CPS_16.01.0002.pdf	Form and Instruction
CMS-P0015A English Section by Section ENS_10.01.0001 ENS_10.01.0001.pdf	Form and Instruction
CMS-P0015A English Section by Section HF_10.01.0002 HF_10.01.0002.pdf	Form and Instruction
CMS-P0015A English Section by Section HI_17.01.0002 HI_17.01.0002.pdf	Form and Instruction
CMS-P0015A English Section by Section HIS_13.01.0001 HIS_13.01.0001.pdf	Form and Instruction
CMS-P0015A English Section by Section IA_08.01.0000 IA_08.01.0000.pdf	Form and Instruction
CMS-P0015A English Section by Section IN_12.01.0000 IN_12.01.0000.pdf	Form and Instruction
CMS-P0015A English Section by Section KN_05.01.0002 KN_05.01.0002.pdf	Form and Instruction
CMS-P0015A English Section by Section NS_18.01.0000.pdf	Form and Instruction
CMS-P0015A English Section by Section OM_09.01.0000.pdf	Form and Instruction
CMS-P0015A English Section by Section PM_14.01.0001.pdf	Form and Instruction
CMS-P0015A English Section by Section RX_07.01.0000.pdf	Form and Instruction
CMS-P0015A English Section by Section SC_09.01.0000.pdf	Form and Instruction
CMS-P0015A English Section by Section ST_15.01.0001.pdf	Form and Instruction
CMS-P0015A MCBS Round 73 Questionnaires Round 73 Questionnaires.pdf	Form and Instruction
Attachments TOC.pdf Table of Contents	IC Document
attachment 2.zip Attachment 2 - Publications	IC Document
Attachment 3.zip Attachment 3 - Letter, Brochure, Agreement	IC Document
attachment07.pdf Attachment 7 - Consent Forms	IC Document
attachment09.pdf Attachment 9 - Impact of Nonsresponse on MCBS Estimates	IC Document
attachment10.pdf Attachment 10 - Primary Sampling Unit Breakdown	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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-P-0015A	Attachment 5 - Facility Screener	Facility Screener May 2012.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	Attachment 6 - MCBS Faclility Round 64 Instruments	attachment 6.zip	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	Attachment 8 - Verification Re-interview	ValidationInterviewCommunityComponent.zip	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	MCBS Household Round 67 Instruments	Attachment 4.zip	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	General Specifications Screen Types_19.01.0001	General Specifications Screen Types_19.01.0001.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	General Specifications Spanish Text_19.01.001	General Specifications Spanish Text_19.01.001.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	Spanish Folder General Specifications Spanish Text_19.01.001	General Specifications Spanish Text_19.01.001.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	English Showcards HI-Eng	HI-Eng.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	Spanish Showcars KN-Sp	KN-Sp.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	English Section by Section CPS_16.01.0002	CPS_16.01.0002.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	English Section by Section ENS_10.01.0001	ENS_10.01.0001.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	English Section by Section HF_10.01.0002	HF_10.01.0002.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	English Section by Section HI_17.01.0002	HI_17.01.0002.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	English Section by Section HIS_13.01.0001	HIS_13.01.0001.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	English Section by Section IA_08.01.0000	IA_08.01.0000.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	English Section by Section IN_12.01.0000	IN_12.01.0000.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	English Section by Section KN_05.01.0002	KN_05.01.0002.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	English Section by Section	NS_18.01.0000.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	English Section by Section	OM_09.01.0000.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	English Section by Section	PM_14.01.0001.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	English Section by Section	RX_07.01.0000.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	English Section by Section	SC_09.01.0000.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	English Section by Section	ST_15.01.0001.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-P0015A	MCBS Round 73 Questionnaires	Round 73 Questionnaires.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16,550

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	49,650	49,650
Annual IC Time Burden (Hours)	58,450	58,450
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Table of Contents	Attachments TOC.pdf	10/25/2013
Attachment 2 - Publications	attachment 2.zip	10/25/2013
Attachment 3 - Letter, Brochure, Agreement	Attachment 3.zip	10/25/2013
Attachment 7 - Consent Forms	attachment07.pdf	10/25/2013
Attachment 9 - Impact of Nonsresponse on MCBS Estimates	attachment09.pdf	10/25/2013
Attachment 10 - Primary Sampling Unit Breakdown	attachment10.pdf	10/25/2013

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