Information Collection

GenIC #25 Medicare Savings Program and Extra Help Awareness Survey

IC 269720 under ICR 202407-0938-019 · OMB 0938-1247.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10437.GenIC#25 GenIC #25 Medicare Savings Program and Extra Help Awareness Survey	Form and Instruction
CMS-10437.GenIC#25 Medicare Savings Program and Extra Help Awareness Survey CMS-10437.GenIC#25.Survey Instrument.docx	Form and Instruction
CMS-10437.GenIC#25 Medicare Savings Program and Extra Help Awareness Survey CMS-10437.GenIC#25.Survey Instrument.docx	Form and Instruction
CMS-10437.GenIC#25.SupportingStatement.docx CMS-10437.GenIC#25.SupportingStatement	IC Document
CMS-10437.GenIC#25.SupportingStatement.docx CMS-10437.GenIC#25.SupportingStatement	IC Document
CMS-10437.GenIC#25. Study Request Form.docx CMS-10437.GenIC#25. Study Request Form	IC Document
CMS-10437.GenIC#25. Study Request Form.docx CMS-10437.GenIC#25. Study Request Form	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-10437.GenIC#25	Medicare Savings Program and Extra Help Awareness Survey	CMS-10437.GenIC#25.Survey Instrument.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
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	333	333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10437.GenIC#25.SupportingStatement	CMS-10437.GenIC#25.SupportingStatement.docx	08/06/2024
CMS-10437.GenIC#25. Study Request Form	CMS-10437.GenIC#25. Study Request Form.docx	08/06/2024

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