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Federal forms, ICRs, and supporting documents

Information Collection

CMS Tribal LTSS Program Survey

IC 229699 under ICR 201801-0938-003 · OMB 0938-1350.

Documents and Forms
Document Name
Document Type
Other-Initial E-mail Invitation
Other-1st Follow up E-mail
Other-2nd Follow up E-mail
Other-3rd Follow up E-mail
Other-Follow-up Phone Script
Other-Follow-up Voicemail Script
Other-Final Follow-up E-mail
Other-Final Follow-up Fax
Form and Instruction
Form
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

CMS Tribal LTSS Program Survey
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Initial E-mail Invitation CMS LTSS_Initial Email Invitation_Attachment C_508_Revised.pdf No   Printable Only
Form and Instruction CMS-10651 CMS Tribal LTSS Program Survey (Screen Shot) CMS LTSS Survey_Survey Screenshot_Attachment D_Revised.pdf Yes Yes Fillable Fileable
Other-1st Follow up E-mail CMS LTSS Survey_First Follow-up Email_Attachment E_508_Revised.pdf No   Printable Only
Other-2nd Follow up E-mail CMS LTSS Survey_Second Follow-up Email_Attachment F_508_Revised.pdf No   Printable Only
Other-3rd Follow up E-mail CMS LTSS Survey_Third Follow-up Email_Attachment G_508_Revised.pdf No   Printable Only
Other-Follow-up Phone Script CMS LTSS Survey_Follow-up Phone Script_Attachment H_508.pdf No   Paper Only
Other-Follow-up Voicemail Script CMS LTSS Survey_Voice Mail Script_Attachment I_508.pdf No   Paper Only
Other-Final Follow-up E-mail CMS LTSS Survey_Final Follow-up Email_Attachment J_508_Revised.pdf No   Printable Only
Other-Final Follow-up Fax CMS LTSS Survey_Final Follow-up Fax_Attachment K_508_Revised.pdf No   Printable Only
Form CMS-10651 CMS Tribal LTSS Program Survey CMS LTSS Survey_Survey_508_Revised_v2.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

425 0
   
State, Local, and Tribal Governments
 
   100 %

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

Title Document Date Uploaded
LTSS Programs CMS LTSS Survey_Tabular form LTSS Programs_Attachment A.pdf 01/09/2018
Survey Followup Timetable CMS LTSS Survey_Follow-up Timeline_Attachment B_508.pdf 01/09/2018
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.