Fall COVID-19 Supplement

Medicare Current Beneficiary Survey (MCBS) COVID-19 Rapid Response Supplement (CMS-P-0015A)

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Fall COVID-19 Supplement	Agency IC Tracking Number:

Is this a Common Form? No		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	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 %

	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

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.