Information Collection

Scheduling/Screening

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Scheduling/Screening	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:

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 %

	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

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.