Form 2 Program Information Form

Consumer Assessment of Healthcare Providers and Systems (CAHPS®)Home and Community Based Services (HCBS) Survey Database

Attachment D Program Information Form_FINAL_7-15-19

Program Information Form

OMB: 0935-0245

Document [docx]
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Please provide the following information. The information you provide for data submission purposes will be kept confidential.



Program Information Form:

Program Identification Number

Associated Agency Identification Number

Program Name

Address1

Address2

City

State

Zip

Program Contact Name

Program Contact Email

Program Contact Phone

Program Setting Type (e.g. Provider-Owned, Individual Residence, etc.)

Population(s) Served (e.g. TBI/Physically Disabled, etc.)

Total Number of Enrollees

Program Funding Sources (e.g. Medicaid/Non-Medicaid, Managed Long-Term Services and Supports)






Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the form. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-xxxx) AHRQ, 5600 Fishers Lane, Rockville, MD 20857.



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorMichael Corrothers
File Modified0000-00-00
File Created2021-01-15

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