DATA COLLECTION FOR ADMINISTERING THE MEDICARE CONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (volunteers)

Testing Experience and Functional Tools: Functional Assessment Standardized Items (FASI) Based on the CARE Tool (CMS-10243)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1037 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10243 DATA COLLECTION FOR ADMINISTERING THE MEDICARE CONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (volunteers) Form and Instruction
CMS-10243 CARE Tool CMS-10243.Appendix B MASTER CARE Tool 30 Day Revisions 103107.doc Form and Instruction
CAREPrototypeScreens20070716.ppt CAREPrototypeScreens20070716 IC Document

Information Collection (IC) Details

IC Title:	DATA COLLECTION FOR ADMINISTERING THE MEDICARE CONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (volunteers)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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-10243	CARE Tool	CMS-10243.Appendix B MASTER CARE Tool 30 Day Revisions 103107.doc		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 238	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-149,940	149,940
Annual IC Time Burden (Hours)	-112,500	112,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CAREPrototypeScreens20070716	CAREPrototypeScreens20070716.ppt	11/15/2007

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