Information Collection

D-SNP Enrollee Advisory Committee and SNP Standardized Questions on Health Risk Assessments

IC 251118 under ICR 202201-0938-008 · OMB 0938-1422.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1422 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix A - Standardized Housing, Food Insecurity, and Transportation Questions For the Special Needs Plan Health Risk Assessme	Instruction
Appendix A - Standardized Housing, Food Insecurity, and Transportation Questions For the Special Needs Plan Health Risk Assessme	Instruction

IC Title:

D-SNP Enrollee Advisory Committee and SNP Standardized Questions on Health Risk Assessments

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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
Instruction			Appendix A - Standardized Housing, Food Insecurity, and Transportation Questions For the Special Needs Plan Health Risk Assessment (CMS-4192-P version 2).pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 383

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	383	383
Annual IC Time Burden (Hours)	10,769	10,769
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.