CMS-10437.GenIC#21 - Testing Form 500

Generic Social Marketing & Consumer Testing Research (CMS-10437)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1247 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10437.GenIC#21 CMS-10437.GenIC#21 - Testing Form 500 Form and Instruction
CMS-10437.GenIC#21 CMS-10437.GenIC#21 - Guide for Testing Form500 (final 11 CMS-10437.GenIC#21 - Guide for Testing Form500 (final 11-24-20).docx Form and Instruction
CMS-10437.GenIC#21-Form500Testing_Supporting Statement (final 11-24-20).docx CMS-10437.GenIC#21-Form500Testing_Supporting Statement (final 11-24-20) IC Document
CMS-10437.GenIC#21 - Justification for Providing Incentives for Participation in Marketing Research.docx CMS-10437.GenIC#21 - Justification for Providing Incentives for Participation in Marketing Research IC Document
CMS-10437.GenIC#21 - Form500StudyInitiationRequestForm.docx CMS-10437.GenIC#21 - Form500StudyInitiationRequestForm IC Document

Information Collection (IC) Details

IC Title:	CMS-10437.GenIC#21 - Testing Form 500	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-10437.GenIC#21 - Guide for Testing Form500 (fi	CMS-10437.GenIC#21 - Guide for Testing Form500 (final 11-24-20)	CMS-10437.GenIC#21 - Guide for Testing Form500 (final 11-24-20).docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 27	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	27	27
Annual IC Time Burden (Hours)	27	27
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10437.GenIC#21-Form500Testing_Supporting Statement (final 11-24-20)	CMS-10437.GenIC#21-Form500Testing_Supporting Statement (final 11-24-20).docx	11/25/2020
CMS-10437.GenIC#21 - Justification for Providing Incentives for Participation in Marketing Research	CMS-10437.GenIC#21 - Justification for Providing Incentives for Participation in Marketing Research.docx	11/25/2020
CMS-10437.GenIC#21 - Form500StudyInitiationRequestForm	CMS-10437.GenIC#21 - Form500StudyInitiationRequestForm.docx	11/25/2020

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