Interview Guide

Medicare Part C and Medicare Part D Enrollment Form Interviews (CMS-10816)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10816 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

Information Collection (IC) Details

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10816	Informed Consent	Attachment D - Informed Consent Form CMS-10816_508.pdf		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10816	Cognitive Interview Protocol	DRAFT Revised Instrument 1- Cognitive Interview Protocol (English)_3.09.23 - CLEAN .docx		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 %

	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

Title	Document	Date Uploaded
Person consulted	Attachment E - Persons Consulted CMS-10816_508.pdf	11/25/2022
Analysis Plan	Attachment F Analysis Plan CMS-10816_508.pdf	11/25/2022

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