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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

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-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 %

table that charts list of burden
	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

table that charts IC Documents
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.