Integrated HRAs (minimal work)

List of Screening Instruments for Housing Stability, Food Security, and Transportation Questions on Health Risk Assessments (HRAs) and Requirements for Integrated HRAs (CMS-10825)

Documents and Forms

Document Name Document Type
CMS-10825_HRA SDOH Guidance (CMS-4208-P version 2).docx Instruction
CMS-10825_HRA SDOH Guidance (CMS-4208-P version 2) REDLINE.pdf REDLINE: Appendix A - List of Screening Instruments IC Document

Information Collection (IC) Details

IC Title:	Integrated HRAs (minimal work)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.101(f)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-10825_HRA SDOH Guidance (CMS-4208-P version 2).docx		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 13	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: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	13	13
Annual IC Time Burden (Hours)	26	26
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
REDLINE: Appendix A - List of Screening Instruments	CMS-10825_HRA SDOH Guidance (CMS-4208-P version 2) REDLINE.pdf	01/27/2025

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