Information Collection

PaRIS Survey

IC 251724 under ICR 202202-0938-004 · OMB 0938-1434.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10792 PaRIS Survey	Form and Instruction
CMS-10792 OECD PaRIS Patient Questionnaire Attach2_PaRIS_Specifications.pdf	Form and Instruction
Attach2_PaRIS_Showcards.pdf PaRIS Showcards	IC Document

IC Title:

PaRIS Survey

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-10792	OECD PaRIS Patient Questionnaire	Attach2_PaRIS_Specifications.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicare Current Beneficiary Survey (MCBS)

FR Citation: 86 FR 8591

Number of Respondents: 5,144

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	5,144	5,144
Annual IC Time Burden (Hours)	3,447	3,447
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
PaRIS Showcards	Attach2_PaRIS_Showcards.pdf	02/22/2022

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