Information Collection

Scheduling/Screening

IC 259110 under ICR 202303-0938-005 · OMB 0938-1456.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10836 Scheduling/Screening	Form and Instruction
CMS-10836 Interview Screener: Typical and Engaged Beneficiaries Plan Performance Warning - A- Beneficiary Screener_112022.pdf	Form and Instruction
CMS-10836 Interview Screener: Typical Beneficiaries: Caregivers Plan Performance Warning - B - Caregivers Screener_112022.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 422.152

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-10836	Interview Screener: Typical and Engaged Beneficiaries	Plan Performance Warning - A- Beneficiary Screener_112022.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10836	Interview Screener: Typical Beneficiaries: Caregivers	Plan Performance Warning - B - Caregivers Screener_112022.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 288

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	288	288
Annual IC Time Burden (Hours)	129	129
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.