Information Collection

CMS Tribal LTSS Program Survey

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10651 CMS Tribal LTSS Program Survey (Screen Shot) CMS Tribal LTSS Program Survey	Form and Instruction
Form CMS-10651 CMS Tribal LTSS Program Survey CMS Tribal LTSS Program Survey	Form
CMS LTSS_Initial Email Invitation_Attachment C_508_Revised.pdf	Other-Initial E-mail Invitation
CMS LTSS Survey_First Follow-up Email_Attachment E_508_Revised.pdf	Other-1st Follow up E-mail
CMS LTSS Survey_Second Follow-up Email_Attachment F_508_Revised.pdf	Other-2nd Follow up E-mail
CMS LTSS Survey_Third Follow-up Email_Attachment G_508_Revised.pdf	Other-3rd Follow up E-mail
CMS LTSS Survey_Follow-up Phone Script_Attachment H_508.pdf	Other-Follow-up Phone Script
CMS LTSS Survey_Voice Mail Script_Attachment I_508.pdf	Other-Follow-up Voicemail Script
CMS LTSS Survey_Final Follow-up Email_Attachment J_508_Revised.pdf	Other-Final Follow-up E-mail
CMS LTSS Survey_Final Follow-up Fax_Attachment K_508_Revised.pdf	Other-Final Follow-up Fax
CMS-10651 CMS Tribal LTSS Program Survey (Screen Shot) CMS LTSS Survey_Survey Screenshot_Attachment D_Revised.pdf	Form and Instruction
CMS-10651 CMS Tribal LTSS Program Survey CMS LTSS Survey_Survey_508_Revised_v2.pdf	Form
CMS LTSS Survey_Tabular form LTSS Programs_Attachment A.pdf LTSS Programs	IC Document
CMS LTSS Survey_Follow-up Timeline_Attachment B_508.pdf Survey Followup Timetable	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Initial E-mail Invitation		No		Printable Only
Form and Instruction	CMS-10651	Yes	Yes	Fillable Fileable
Other-1st Follow up E-mail		No		Printable Only
Other-2nd Follow up E-mail		No		Printable Only
Other-3rd Follow up E-mail		No		Printable Only
Other-Follow-up Phone Script		No		Paper Only
Other-Follow-up Voicemail Script		No		Paper Only
Other-Final Follow-up E-mail		No		Printable Only
Other-Final Follow-up Fax		No		Printable Only
Form	CMS-10651	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 425

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	425	425
Annual IC Time Burden (Hours)	106	106
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
LTSS Programs		01/09/2018
Survey Followup Timetable		01/09/2018

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

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