CMS Tribal LTSS Program Survey

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

Documents and Forms

Document Name Document Type
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

Information Collection (IC) Details

IC Title:	CMS Tribal LTSS Program Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	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

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 %

	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

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.