Information Collection

Survey: Rounds 1 and 2

IC 251708 under ICR 202202-0938-005 · OMB 0938-1430.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10786 Survey: Rounds 1 and 2	Form and Instruction
SUPPORT Act 1003 Provider Survey _Crosswalk.xlsx	Other-Crosswalk: Survey
SUPPORT Act 1003 Provider Survey _Crosswalk.xlsx	Other-Crosswalk: Survey
CMS-10786 Survey of Medicaid Opioid Use Disorder Treatment Provide providersurvey_SUPPORTAct1003.pdf	Form and Instruction
CMS-10786 Survey of Medicaid Opioid Use Disorder Treatment Provide providersurvey_SUPPORTAct1003.pdf	Form and Instruction

IC Title:

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-10786	Survey of Medicaid Opioid Use Disorder Treatment Providers	providersurvey_SUPPORTAct1003.pdf		Yes	Yes	Fillable Fileable
Other-Crosswalk: Survey			SUPPORT Act 1003 Provider Survey _Crosswalk.xlsx		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 28,670

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	28,670	28,670
Annual IC Time Burden (Hours)	7,168	7,168
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.