Information Collection

CMS-10731(GenIC#1). Was This Page Helpful Survey

IC 272113 under ICR 202304-0938-022 · OMB 0938-1459.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10731. (GenIC# CMS-10731(GenIC#1). Was This Page Helpful Survey	Form and Instruction
CMS-10731. (GenIC# CMS-10731 (GenIC#1). Was This Page Helfpul Survey CMS-10731 (GenIC#1). Was This Page Helfpul Survey .docx	Form and Instruction
CMS-10731 (GenIC#1). Fast Track Submission Request.docx CMS-10731 (GenIC#1). Fast Track Submission Request	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: New

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-10731. (GenIC#1)	CMS-10731 (GenIC#1). Was This Page Helfpul Survey	CMS-10731 (GenIC#1). Was This Page Helfpul Survey .docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,000

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10731 (GenIC#1). Fast Track Submission Request	CMS-10731 (GenIC#1). Fast Track Submission Request.docx	11/04/2024

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