Information Collection

Partner Survey

IC 226367 under ICR 202301-0938-018 · OMB 0938-1342.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10632 Partner Survey	Form and Instruction
Form CMS-10632 Partner Survey	Form and Instruction
CMS-10632 Appendix A - Partner Survey: Informed Consent and Survey CMS-10632.Appendix_A_Partner_Survey_srs_022221.pdf	Form and Instruction
CMS-10632 Appendix A - Partner Survey: Informed Consent and Survey CMS-10632.Appendix_A_Partner_Survey_srs_022221.pdf	Form and Instruction
CMS-10632.Appendix_C_Recruitment_Script_srs_022221.pdf Recruitment script	IC Document
CMS-10632.Appendix_C_Recruitment_Script_srs_022221.pdf Recruitment script	IC Document
CMS-10632.Appendix_D_Support_Letter_from_CMS_OMH_srs_012221LM.pdf Letter of Support	IC Document
CMS-10632.Appendix_D_Support_Letter_from_CMS_OMH_srs_012221LM.pdf Letter of Support	IC Document

IC Title:

Partner Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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 and Instruction	CMS-10632	Appendix A - Partner Survey: Informed Consent and Survey	CMS-10632.Appendix_A_Partner_Survey_srs_022221.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Recruitment script	CMS-10632.Appendix_C_Recruitment_Script_srs_022221.pdf	05/06/2021
Letter of Support	CMS-10632.Appendix_D_Support_Letter_from_CMS_OMH_srs_012221LM.pdf	05/06/2021

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