Information Collection

HCBS Incident Management Survey

IC 235360 under ICR 201903-0938-008 · OMB 0938-1362.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1362 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10692 HCBS Incident Management Survey Form and Instruction
Introductory- Email-for-IM Survey.docx Other-Introductory E-mail
CMS-10692 HCBS Incident Management Survey CIM Survey Final (1).pdf navigantmarketing.co1.qualtrics.com/jfe/form/SV_6id5ehNBH6LuU5v Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HCBS Incident Management Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10692	HCBS Incident Management Survey	CIM Survey Final (1).pdf	https://navigantmarketing.co1.qualtrics.com/jfe/form/SV_6id5ehNBH6LuU5v	Yes	Yes	Fillable Fileable
Other-Introductory E-mail			Introductory- Email-for-IM Survey.docx		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	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	102	102
Annual IC Time Burden (Hours)	153	153
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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