Information Collection

Mode Experiment

IC 209906 under ICR 202107-0938-015 · OMB 0938-1240.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1240 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10500 Mode Experiment	Form
Form CMS-10500 OAS CAHPS (Mail Survey) Mode Experiment	Form
Form CMS-10500 OAS CAHPS (Telephone Script) Mode Experiment	Form and Instruction
Form CMS-10500 OAS CAHPS (Web Survey Screenshots) Mode Experiment	Form and Instruction
CMS-10500 OAS CAHPS (Mail Survey) Attachment A - Mail Questionnaire [07-31-2018].docx	Form
CMS-10500 OAS CAHPS (Mail Survey) Attachment A - Mail Questionnaire [07-31-2018].docx	Form
CMS-10500 OAS CAHPS (Telephone Script) Attachment B - CATI Questionnaire [07-31-2018].docx	Form and Instruction
CMS-10500 OAS CAHPS (Telephone Script) Attachment B - CATI Questionnaire [07-31-2018].docx	Form and Instruction
CMS-10500 OAS CAHPS (Web Survey Screenshots) Attachment C - Web Questionnaire [07-31-2018].docx	Form and Instruction
CMS-10500 OAS CAHPS (Web Survey Screenshots) Attachment C - Web Questionnaire [07-31-2018].docx	Form and Instruction
OAS CAHPS NI-ME Attachment D1-Cover_Letters - Mail Mode.docx Cover Letters (Mail Mode)	IC Document
OAS CAHPS NI-ME Attachment D1-Cover_Letters - Mail Mode.docx Cover Letters (Mail Mode)	IC Document
OAS CAHPS ME Attachment D2-Letter Invitation for Web Survey_1st Contact.....docx Letter Invitation (Web Survey) First Contact	IC Document
OAS CAHPS ME Attachment D2-Letter Invitation for Web Survey_1st Contact.....docx Letter Invitation (Web Survey) First Contact	IC Document
OAS CAHPS ME Attachment D3-Email Invitation for Web Survey_Reminder Cont....docx E-mail Invitation (Web Survey) First Contact	IC Document
OAS CAHPS ME Attachment D3-Email Invitation for Web Survey_Reminder Cont....docx E-mail Invitation (Web Survey) First Contact	IC Document
OAS CAHPS ME Attachment D4-Email Invitation for Web Survey_Reminder Cont....docx E-mail Invitation (Web Survey) Reminder	IC Document
OAS CAHPS ME Attachment D4-Email Invitation for Web Survey_Reminder Cont....docx E-mail Invitation (Web Survey) Reminder	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Mode Experiment

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10500	No		Fillable Fileable
Form and Instruction	CMS-10500	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10500	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,850

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-7,850	7,850
Annual IC Time Burden (Hours)	-1,021	1,021
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Letters (Mail Mode)		07/31/2018
Letter Invitation (Web Survey) First Contact		07/31/2018
E-mail Invitation (Web Survey) First Contact		07/31/2018
E-mail Invitation (Web Survey) Reminder		07/31/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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