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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

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-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 %

table that charts list of burden
	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

table that charts IC Documents
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.