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

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (CMS-10415)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10591 Cognitive Testing for the Marketplace Dental Survey (CMS-10591) 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 Generic Clearance Submission Form_MDS Cognitive Testing IC Document

Information Collection (IC) Details

IC Title:	Cognitive Testing for the Marketplace Dental Survey (CMS-10591)	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-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 %

	Requested	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

Title	Document	Date Uploaded
Generic Clearance Submission Form_MDS Cognitive Testing	Generic Clearance Submission Form_MDS Cognitive Testing_10-29-15.doc	12/29/2015

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