CMS Tribal Long Term Services and Supports (LTSS) Program Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
TTAG_concur_Annual_Tribal_LTSS_Survey.pdf	Supplementary Document	Uploaded 2018-03-05	Available
CMS-10651 - Supporting Statement B (rev OSORA PRA).docx	Supporting Statement B	Uploaded 2018-01-09	Available
CMS-10651 - Supporting Statement A (rev OSORA PRA).docx	Supporting Statement A	Uploaded 2018-01-09	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
229699	CMS Tribal LTSS Program Survey	Other-Initial E-mail Invitation	New

ICR Details

OMB Control No: 0938-1350	ICR Reference No: 201801-0938-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: CMS Tribal Long Term Services and Supports (LTSS) Program Survey
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/06/2018
	Date Received in OIRA: 01/10/2018
Terms of Clearance: We appreciate CMS' consultation with the Tribal Technical Advisory Group on the utility of this collection.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2021	36 Months From Approved
Responses	425	0	0
Time Burden (Hours)	106	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The CMS Tribal Long Term Services and Supports (LTSS) Program Survey will provide CMS with an inventory of LTSS programs for older adults or individuals with disabilities managed by American Indian and Alaska Native (AI/AN) tribes. Information on tribal LTSS programs has previously been gathered through collection of publicly available data via online research. However, not all of the information, including program contact information and program focus, are regularly available online as tribal websites are not updated frequently. Therefore, the survey will enable the collection of the most accurate information possible. Once the survey has been conducted, CMS will feature the survey data, specifically a list of AI/AN managed LTSS programs, online on CMS.gov. Dissemination of survey data on CMS.gov will allow tribal communities and the general public to access this important data. Documentation of these programs will support sharing of LTSS best practices and innovative models employed in Indian Country. CMS will use the survey data to generate further content on LTSS in Indian Country, including literature reviews and reports on best practices.

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Authorizing Statute(s): PL: Pub.L. 111 - 5 50006(e)(1) Name of Law: American Recovery and Reinvestment Act of 2009
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 31331	07/06/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 48719	10/19/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
CMS Tribal LTSS Program Survey	CMS-10651, CMS-10651	CMS Tribal LTSS Program Survey (Screen Shot) ,   CMS Tribal LTSS Program Survey

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	425	0	0	425	0	0
Annual Time Burden (Hours)	106	0	0	106	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: At 15 min/per response and 425 responses, the Survey will provide CMS with an inventory of LTSS programs for older adults or individuals with disabilities managed by American Indian and Alaska Native (AI/AN) tribes. Information on tribal LTSS programs has previously been gathered through collection of publicly available data via online research. However, not all of the information, including program contact information and program focus, are regularly available online as tribal websites are not updated frequently. Therefore, the survey will enable the collection of the most accurate information possible.

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Annual Cost to Federal Government: $91,896

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Yes

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/10/2018

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