CMS-10651 CMS Tribal LTSS Program Survey (Screen Shot)

CMS Tribal LTSS Program Survey

Please take a few minutes to complete the survey below. The purpose of this survey is to obtain information
to help the Centers for Medicare and Medicaid (CMS) develop of a list of tribally operated long-term services
and supports (LTSS) programs across Indian Country. Tribes and tribal organizations may provide these
services directly, or through a contract or agreement with an outside organization. LTSS are a set of health
care, personal care, and social services delivered over an extended period to help persons who are unable
to independently perform activities of daily living, such as getting in and out of bed, dressing, bathing,
eating, and using the bathroom. LTSS may be provided in community and institutional settings or in a
person’s own home.
Your response is voluntary. The information from this survey will be shared online on the CMS’ LTSS Technical
Assistance Center webpage. Thank you for your time.
PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to
respond to a collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-New (Expires: TBD). The time required to complete this
information collection is estimated to average 15 minutes per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions
for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

The following questions are about types of LTSS that your tribe/tribal program offers or coordinates.

1. Does your tribe/tribal program have a senior center?

š

Yes

š

No

2. Does your tribe/tribal program provide independent senior housing?
(Independent senior housing: Homes or apartments reserved specifically for older adults or people with disabilities who do not need assistance
with activities of daily living.)

š

Yes

š

No

3. Does your tribe/tribal program have an assisted living facility?
(Assisted living facilities: Facilities of any size—including adult foster homes, group homes, or congregate housing—that provide housing and
personal care services, such as meals, housekeeping, transportation, and assistance with activities of daily living, as needed, to persons who can
still live independently in their homes.)

š

Yes

š

No

4. Does your tribe/tribal program have an adult day care program?
(Adult day care programs: Non-residential facilities that support the daily living and social needs of elderly or chronically ill adults or people with
disabilities.)