Information Collection

CMS Age-Friendly Readiness Assessment (CMS-10965)

IC 280617 under ICR 202405-0938-010 · OMB 0938-1397.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10965 Age Friendly Readiness Assessment CMS Age-Friendly Readiness Assessment (CMS-10965)	Form and Instruction
Form CMS-10965 Age Friendly Survey Scoring CMS Age-Friendly Readiness Assessment (CMS-10965)	Form and Instruction
Form CMS-10965 QIO Participant Age-Friendly Survey CMS Age-Friendly Readiness Assessment (CMS-10965)	Form and Instruction
CMS-10965 Age Friendly Readiness Assessment Creating a AgeFriendlyreadinessAssessnebt_Coordinator_lcv_051226.docx	Form and Instruction
CMS-10965 Age Friendly Survey Scoring AgeFriendly Survey Scoring_51426LCV0330.docx	Form and Instruction
CMS-10965 QIO Participant Age-Friendly Survey CMS-10965 QIO_Age Friendly Survey_systempracticehospital 7-20-26 clean.docx	Form and Instruction
CMS-10965_CMS-HRSA Rapid PRA 7-20-26 clean.docx Supporting Statement	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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10965	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10965	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10965	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,612

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

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	5,612	5,612
Annual IC Time Burden (Hours)	1,870	1,870
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement		07/30/2026

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

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