Information Collection

CMS-10549 GenIC#7 - MCBS COVID-19 Rapid Response Supplement Testing

IC 241697 under ICR 202004-0938-011 · OMB 0938-1275.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1275 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10549 CMS-10549 GenIC#7 - MCBS COVID-19 Rapid Response Supplement Testing Form and Instruction
CMS-10549 Questionnaire Attachment C. Questionnaire.docx Form and Instruction
Attachment A. Advance Letter.docx Advance Letter IC Document
Attachment B. Contacting Script.docx Contacting Script IC Document
MCBS COVID-19 Rapid Response Supplement Generic Clearance.docx CMS-10549.GenIC#7 - Mini Supporting Statement IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CMS-10549 GenIC#7 - MCBS COVID-19 Rapid Response Supplement Testing	Agency IC Tracking Number:	ODEA

IC Status: New

Obligation to Respond: Voluntary

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-10549	Questionnaire	Attachment C. Questionnaire.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,949	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10,949	10,949
Annual IC Time Burden (Hours)	2,737	2,737
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Advance Letter	Attachment A. Advance Letter.docx	05/05/2020
Contacting Script	Attachment B. Contacting Script.docx	05/05/2020
CMS-10549.GenIC#7 - Mini Supporting Statement	MCBS COVID-19 Rapid Response Supplement Generic Clearance.docx	05/05/2020

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