Information Collection

MACBIS Software Application Electronic Surveys for Users (CMS-10719)

IC 238454 under ICR 201904-0938-017 · OMB 0938-1185.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1185 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10719 MACBIS Software Application Electronic Surveys for Users (CMS-10719)	Form
CMS-10719 MACBIS Software Application Electronic Surveys for Users Instrument_MACBIS Software Application Electronic Surveys for Users (version 3) CLEAN.docx	Form
CMS-10719 - Fast Track Supporting Statement (version 3).doc Fast Track Supporting Statement	IC Document

IC Title:

MACBIS Software Application Electronic Surveys for Users (CMS-10719)

Agency IC Tracking Number:

CMCS

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	CMS-10719	MACBIS Software Application Electronic Surveys for Users	Instrument_MACBIS Software Application Electronic Surveys for Users (version 3) CLEAN.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,081

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	2,081	2,081
Annual IC Time Burden (Hours)	173	173
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Fast Track Supporting Statement	CMS-10719 - Fast Track Supporting Statement (version 3).doc	11/08/2019

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