Beneficiary Survey

Value in Opioid Use Disorder Treatment Demonstration (CMS-10728)

Documents and Forms

Document Name Document Type
Form CMS-10728 Beneficiary Survey Form and Instruction
CMS-10728 Beneficiary Health Survey PRA-OUD-Demo-Health Survey-Instrument (SF-36)_02.2020-CLEAN.docx Form and Instruction
CMS-10728 Beneficiary Health Survey PRA-OUD-Demo-Health Survey-Instrument (SF-36)_02.2020-CLEAN.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Beneficiary Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 1866F (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10728	Beneficiary Health Survey	PRA-OUD-Demo-Health Survey-Instrument (SF-36)_02.2020-CLEAN.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Master Demonstration, Evaluation, and Research Studies for the Office of Research Development and Information (DERS)	FR Citation: 83 FR 6591

Number of Respondents: 100	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	Previously Approved
Annual Number of Responses for this IC	100	-400	500
Annual IC Time Burden (Hours)	8	-32	40
Annual IC Cost Burden (Dollars)	0	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.