Information Collection

Standardized Survey

IC 235214 under ICR 201903-0938-004 · OMB 0938-1364.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10688 HHA Survey Instrument Standardized Survey	Form and Instruction
CMS-10688 HHA Survey Instrument Attachment II - HHA Survey Instrument-CLEAN-Revised V2.pdf	Form and Instruction
Attachment V - Web Survey Invitation Email 508.pdf Web Survey Invitation Email	IC Document
Attachment VI - Reminder Email 508.pdf Reminder Email	IC Document
Attachment VII - First Mail Survey Cover Letter 508.pdf First Mail Survey Cover Letter	IC Document
Attachment VIII - Mail Survey Reminder Letter 508.pdf Mail Survey Reminder Letter	IC Document
Attachment X - List of Quality Measures 508.pdf List of Quality Measures	IC Document
Attachment I - Development of HH Survey 508.pdf Development of HH Survey	IC Document

IC Title:

Standardized Survey

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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10688				Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000

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	1,000	1,000
Annual IC Time Burden (Hours)	1,000	1,000
Annual IC Cost Burden (Dollars)	118,700	118,700

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Web Survey Invitation Email		03/07/2019
Reminder Email		03/07/2019
First Mail Survey Cover Letter		03/07/2019
Mail Survey Reminder Letter		03/07/2019
List of Quality Measures		03/07/2019
Development of HH Survey		03/07/2019

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

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