HCBS Incident Management Survey

Home and Community Based Services (HCBS) Incident Management Survey (CMS-10692)

Documents and Forms

Document Name Document Type
CMS-10692. Introductory- Email-for-IM Survey.pdf Other-Introductory Email
CMS-10692. Introductory- Email-for-IM Survey.pdf Other-Introductory Email
CMS-10692 CIM Survey Final.pdf CMS-10698. CIM Survey Final.pdf Form and Instruction
CMS-10692 CIM Survey Final.pdf CMS-10698. CIM Survey Final.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	HCBS Incident Management Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Introductory Email			CMS-10692. Introductory- Email-for-IM Survey.pdf		Yes	No	Printable Only
Form and Instruction	CMS-10692	CIM Survey Final.pdf	CMS-10698. CIM Survey Final.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	102	102
Annual IC Time Burden (Hours)	153	153
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.