Consumer Survey

Evaluating Coverage to Care in Communities (CMS-10632)

OMB: 0938-1342

IC ID: 226369

Information Collection (IC) Details

View Information Collection (IC)

Consumer Survey
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10632 Appendix B Consumer Survey: Informed Consent and Survey CMS-10632.Appendix_B_Consumer_Survey_srs_022221.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

400 0
   
Individuals or Households
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 400 0 400 0 0 0
Annual IC Time Burden (Hours) 132 0 132 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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