Information Collection

(CMS-10591) Cognitive Testing for the Marketplace Dental Survey

IC 218995 under ICR 201506-0938-013 · OMB 0938-1185.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1185 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10591 Marketplace Dental Survey Cognitive Testing Eligibility Screener (CMS-10591) Cognitive Testing for the Marketplace Dental Survey	Form and Instruction
CMS-10591 Marketplace Dental Survey Cognitive Testing Eligibility Combined MDS OMB Submission Items Clean 111615.doc	Form and Instruction
Generic Clearance Submission Form_MDS Cognitive Testing_10-29-15.doc Cognitive Testing for the Marketplace Dental Survey	IC Document

IC Title:

(CMS-10591) Cognitive Testing for the Marketplace Dental Survey

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-10591	Marketplace Dental Survey Cognitive Testing Eligibility Screener	Combined MDS OMB Submission Items Clean 111615.doc		No		Paper Only

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
Cognitive Testing for the Marketplace Dental Survey	Generic Clearance Submission Form_MDS Cognitive Testing_10-29-15.doc	11/16/2015

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