Information Collection

CMS-10549.GenIC#3 - MCBS Cognitive Testing Self-Management Items

IC 233217 under ICR 201801-0938-008 · OMB 0938-1275.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1275 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10549.GenIC#3 CMS-10549.GenIC#3 - MCBS Cognitive Testing Self-Management Items Form
CMS-10549.GenIC#3 Screening Instrument CMS-10549#3 - Att. C Screening Instrument (OIRA Passback)_OEDA Reviewed..._.docx Form
CMS-10549.GenIC#3 Questionnaire CMS-10549.GenIC#3 - Att. E Questionnaire.docx Form and Instruction
CMS-10549.GenIC#3 - Att. B Recruitment Script.docx CMS-10549.GenIC#3 - Att. B Recruitment Script IC Document
CMS-10549.GenIC#3 - Att. D Consent Form.docx CMS-10549.GenIC#3 - Att. D Consent Form IC Document
CMS-10549.GenIC#3 - Att. F Showcard HF5.pdf CMS-10549.GenIC#3 - Att. F Showcard HF5 IC Document
CMS-10549.GenIC#3 - Att. G Participant Fee Receipt.docx CMS-10549.GenIC#3 - Att. G Participant Fee Receipt IC Document
CMS-10549.GenIC#3 - Att. H MCBS FAQ.docx CMS-10549.GenIC#3 - Att. H MCBS FAQ IC Document
CMS-10549.GenIC#3 - Att. A Recruitment Flyers.docx CMS-10549.GenIC#3 - Att. A Recruitment Flyers IC Document
CMS-10549.GenIC#3 - MCBS Cognitive Testing Self-Management Items - Mini Supporting Statement.docx CMS-10549.GenIC#3 - MCBS Cognitive Testing Self-Management Items - Mini Supporting Statement IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CMS-10549.GenIC#3 - MCBS Cognitive Testing Self-Management Items	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10549.GenIC#3 Attachment C	Screening Instrument	CMS-10549#3 - Att. C Screening Instrument (OIRA Passback)_OEDA Reviewed..._.docx		Yes	No	Fillable Fileable
Form and Instruction	CMS-10549.GenIC#3 Attachment E	Questionnaire	CMS-10549.GenIC#3 - Att. E Questionnaire.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 41	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	41	41
Annual IC Time Burden (Hours)	22	22
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10549.GenIC#3 - Att. B Recruitment Script	CMS-10549.GenIC#3 - Att. B Recruitment Script.docx	09/26/2018
CMS-10549.GenIC#3 - Att. D Consent Form	CMS-10549.GenIC#3 - Att. D Consent Form.docx	09/26/2018
CMS-10549.GenIC#3 - Att. F Showcard HF5	CMS-10549.GenIC#3 - Att. F Showcard HF5.pdf	09/26/2018
CMS-10549.GenIC#3 - Att. G Participant Fee Receipt	CMS-10549.GenIC#3 - Att. G Participant Fee Receipt.docx	09/26/2018
CMS-10549.GenIC#3 - Att. H MCBS FAQ	CMS-10549.GenIC#3 - Att. H MCBS FAQ.docx	09/26/2018
CMS-10549.GenIC#3 - Att. A Recruitment Flyers	CMS-10549.GenIC#3 - Att. A Recruitment Flyers.docx	09/26/2018
CMS-10549.GenIC#3 - MCBS Cognitive Testing Self-Management Items - Mini Supporting Statement	CMS-10549.GenIC#3 - MCBS Cognitive Testing Self-Management Items - Mini Supporting Statement.docx	09/26/2018

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