Information Collection

Interview Guide

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10816 Interview Guide	Form and Instruction
Form CMS-10816 Informed Consent Interview Guide	Form and Instruction
Form CMS-10816 Cognitive Interview Protocol Interview Guide	Form and Instruction
CMS-10816 Informed Consent Attachment D - Informed Consent Form CMS-10816_508.pdf	Form and Instruction
CMS-10816 Informed Consent Attachment D - Informed Consent Form CMS-10816_508.pdf	Form and Instruction
CMS-10816 Cognitive Interview Protocol Attachment A_Revised Interview Protocol for Medicare Parts CD Cognitive Interview Study clean.docx	Form and Instruction
CMS-10816 Cognitive Interview Protocol Attachment A_Revised Interview Protocol for Medicare Parts CD Cognitive Interview Study clean.docx	Form and Instruction
Attachment E - Persons Consulted CMS-10816_508.pdf Person consulted	IC Document
Attachment E - Persons Consulted CMS-10816_508.pdf Person consulted	IC Document
Attachment F Analysis Plan CMS-10816_508.pdf Analysis Plan	IC Document
Attachment F Analysis Plan CMS-10816_508.pdf Analysis Plan	IC Document

IC Title:

Interview Guide

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 422.60 42 CFR 422.50 42 CFR 423.32

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-10816				Yes	Yes	Fillable Printable
Form and Instruction	CMS-10816				Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicare Advantage Prescription Drug (MARx)

FR Citation: 83 FR 6591

Number of Respondents: 130

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

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Person consulted		11/25/2022
Analysis Plan		11/25/2022

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

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