Organizational Survey

Evaluating Coverage to Care (C2C) (CMS-10632)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1342 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10632 Organizational Survey Form and Instruction
CMS-10632 Appendix A - Organization Survey: Informed Consent and S CMS-10632.Appendix A - Organizational Survey.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Organizational Survey	Agency IC Tracking Number:

Is this a Common Form? No		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-10632	Appendix A - Organization Survey: Informed Consent and Survey	CMS-10632.Appendix A - Organizational Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	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: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	198	198
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.