OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Interview Guide

IC 257119 under ICR 202312-0938-005 · OMB 0938-1440.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Interview Guide
 
No Modified
 
Voluntary
 
42 CFR 422.60 42 CFR 422.50 42 CFR 423.32

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10816 Informed Consent Attachment D - Informed Consent Form CMS-10816_508.pdf Yes Yes Fillable Printable
Form and Instruction CMS-10816 Cognitive Interview Protocol Attachment A_Revised Interview Protocol for Medicare Parts CD Cognitive Interview Study clean.docx Yes Yes Fillable Printable

Health Health Care Services

Medicare Advantage Prescription Drug (MARx)  83 FR 6591

130 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 130 0 0 10 0 120
Annual IC Time Burden (Hours) 65 0 6 -25 0 84
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Person consulted Attachment E - Persons Consulted CMS-10816_508.pdf 11/25/2022
Analysis Plan Attachment F Analysis Plan CMS-10816_508.pdf 11/25/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.