Information Collection

Interview Guide

IC 257119 under ICR 202211-0938-013 · OMB 0938-1440.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1440 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10816 Interview Guide	Form and Instruction
Form CMS-10816 Informed Consent Interview Guide	Form and Instruction
Form CMS-10816 Cognitive Interview Protocol Interview Guide	Form and Instruction
CMS-10816 Informed Consent Attachment D - Informed Consent Form CMS-10816_508.pdf	Form and Instruction
CMS-10816 Informed Consent Attachment D - Informed Consent Form CMS-10816_508.pdf	Form and Instruction
CMS-10816 Cognitive Interview Protocol Instrument 1 - Cognitive Interview Protocol (English) CMS-10816_508.pdf	Form and Instruction
CMS-10816 Cognitive Interview Protocol DRAFT Revised Instrument 1- Cognitive Interview Protocol (English)_3.09.23 - CLEAN .docx	Form and Instruction
Attachment E - Persons Consulted CMS-10816_508.pdf Person consulted	IC Document
Attachment E - Persons Consulted CMS-10816_508.pdf Person consulted	IC Document
Attachment F Analysis Plan CMS-10816_508.pdf Analysis Plan	IC Document
Attachment F Analysis Plan CMS-10816_508.pdf Analysis Plan	IC Document

IC Title:

Interview Guide

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 423.32 42 CFR 422.60 42 CFR 422.50

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-10816				Yes	Yes	Fillable Printable
Form and Instruction	CMS-10816				Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicare Advantage Prescription Drug (MARx)

FR Citation: 83 FR 6591

Number of Respondents: 120

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	84	84
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Person consulted		11/25/2022
Analysis Plan		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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