Information Collection

MACBIS Software Application Electronic Surveys for Users (CMS-10719)

IC 257106 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10719 MACBIS Software Application Electronic Surveys for Users (CMS-10719)	Form
Form CMS-10719 MACBIS Software Application Electronic Surveys for Users MACBIS Software Application Electronic Surveys for Users (CMS-10719)	Form
CMS-10719 MACBIS Software Application Electronic Surveys for Users Instrument_MACBIS Software Application Electronic Surveys for Users (version 3) CLEAN.docx	Form
CMS-10719 MACBIS Software Application Electronic Surveys for Users Instrument_MACBIS Software Application Electronic Surveys for Users (version 3) CLEAN.docx	Form
CMS-10719 - Fast Track Supporting Statement (version 3).docx CMS-10719 - Fast Track Supporting Statement (version 3)	IC Document
CMS-10719 - Fast Track Supporting Statement (version 3).docx CMS-10719 - Fast Track Supporting Statement (version 3)	IC Document

IC Title:

Agency IC Tracking Number:

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	CMS-10719				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,081

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,081	2,081
Annual IC Time Burden (Hours)	173	173
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10719 - Fast Track Supporting Statement (version 3)		11/25/2022

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

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