Information Collection

HCBS Incident Management Survey

IC 235360 under ICR 202206-0938-024 · OMB 0938-1362.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of 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 %

table that charts list of burden
	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

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.