Information Collection

Telephone survey

IC 225194 under ICR 201701-0938-003 · OMB 0938-1339.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10634 Telephone survey	Form
40400 OMB Appendix A2.pdf	Other-Selection Letter (English and
40400 OMB Appendix A3.pdf	Other-Selection Postcards (English a
CMS-10634 Medicaid Postpartum Survey 40400 OMB Appendix A1a [rev 01-20-2017 by OSORA PRA].pdf	Form
CMS-10634 Medicaid Postpartum Survey (Spanish) 40400 OMB Appendix A1b [rev 01-20-2017 by OSORA PRA].pdf	Form

IC Title:

Telephone survey

Agency IC Tracking Number:

Is this a Common Form? No

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10634	Medicaid Postpartum Survey	40400 OMB Appendix A1a [rev 01-20-2017 by OSORA PRA].pdf	Yes	Yes	Fillable Fileable
Form	CMS-10634	Medicaid Postpartum Survey (Spanish)	40400 OMB Appendix A1b [rev 01-20-2017 by OSORA PRA].pdf	Yes	Yes	Fillable Fileable
Other-Selection Letter (English and Spanish)			40400 OMB Appendix A2.pdf	No		Paper Only
Other-Selection Postcards (English and Spanish)			40400 OMB Appendix A3.pdf	No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,560

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	1,560	1,560
Annual IC Time Burden (Hours)	780	780
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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