Information Collection

Mode Experiment

IC 249727 under ICR 202110-0938-005 · OMB 0938-1404.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10784 Mode Experiment	Form and Instruction
Form CMS-10784 Home Health Care CAHPS Mail Survey Mode Experiment	Form and Instruction
Form CMS-10784 Home Health Care CAHPS Web Survey Mode Experiment	Form and Instruction
CMS-10784 Home Health Care CAHPS Mail Survey AttachAMailSurvey.pdf	Form and Instruction
CMS-10784 Home Health Care CAHPS Mail Survey AttachAMailSurvey.pdf	Form and Instruction
CMS-10784 Home Health Care CAHPS Web Survey AttachCWebSurveyScreenshots.pdf	Form and Instruction
CMS-10784 Home Health Care CAHPS Web Survey AttachCWebSurveyScreenshots.pdf	Form and Instruction
AttachBTelephoneScript.pdf Telephone Script	IC Document
AttachBTelephoneScript.pdf Telephone Script	IC Document
AttachD1InitialCoverLtrMailSur.pdf Initial Cover letter (Mail)	IC Document
AttachD1InitialCoverLtrMailSur.pdf Initial Cover letter (Mail)	IC Document
AttachD2LtrInviteWebSurvey.pdf Web Invite Letter	IC Document
AttachD2LtrInviteWebSurvey.pdf Web Invite Letter	IC Document

IC Title:

Mode Experiment

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	CMS-10784				No		Fillable Printable
Form and Instruction	CMS-10784				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,280

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	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	6,280	6,280
Annual IC Time Burden (Hours)	1,049	1,049
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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

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