Information Collection

Beneficiary Survey

IC 242934 under ICR 202007-0938-012 · OMB 0938-1388.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1388 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10728 Beneficiary Survey	Form and Instruction
CMS-10728 Beneficiary Health Survey PRA-OUD-Demo-Health Survey-Instrument (SF-36)_02.2020-CLEAN.docx	Form and Instruction

IC Title:

Beneficiary Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 1866F (To search for a specific CFR, visit the Code of Federal Regulations.)

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-10728	Beneficiary Health Survey	PRA-OUD-Demo-Health Survey-Instrument (SF-36)_02.2020-CLEAN.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Master Demonstration, Evaluation, and Research Studies for the Office of Research Development and Information (DERS)

FR Citation: 83 FR 6591

Number of Respondents: 500

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	500	500
Annual IC Time Burden (Hours)	40	40
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.