Information Collection

Fall COVID-19 Supplement

IC 242742 under ICR 202007-0938-005 · OMB 0938-1379.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form P-0015A Fall COVID-19 Supplement	Form and Instruction
P-0015A COVID-19 Community Supplement Attachment 2. MCBS Fall 2020 COVID-19 Community Supplement.docx	Form and Instruction
P-0015A COVID-19 Facility Supplement Attachment 3. MCBS Fall 2020 COVID-19 Facility Supplement_clean.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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	P-0015A	COVID-19 Community Supplement	Attachment 2. MCBS Fall 2020 COVID-19 Community Supplement.docx		Yes	Yes	Fillable Fileable
Form and Instruction	P-0015A	COVID-19 Facility Supplement	Attachment 3. MCBS Fall 2020 COVID-19 Facility Supplement_clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicare Current Beneficiary Survey (MCBS)

FR Citation: 83 FR 6591

Number of Respondents: 11,536

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	11,536	11,536
Annual IC Time Burden (Hours)	2,884	2,884
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.