Medicare Current Beneficiary Survey (MCBS) (CMS-P-0015A)

Forms and Documents

Document	Type	Status	Availability
Form CMS-P-0015A Interviewer_Remarks	Form	Modified	Available
Form CMS-P-0015A Health_Status	Form	Modified	Available
Form CMS-P-0015A Immunization	Form	Modified	Available
Form CMS-P-0015A Physical Measures Frequently Asked Questions (FAQ) Sheet	Form	Modified	Available
Form CMS-P-0015A Telemedicine Questionnaire	Form	Modified	Available
Form CMS-P-0015A Use of Health Services Section Specifications	Form	Modified	Available
Form P-0015A COVID-19 Facility-Level Supplement	Form	Modified	Available
Form P-0015A COVID-19 Questionnaire Specifications	Form	Modified	Available
Form CMS-P-0015A Physical_Measures	Form	Modified	Available
Form CMS-P-0015A HFQ - Health Status and Functioning	Form	Modified	Available
Form CMS-P-0015A Cognitive Measures	Form	Modified	Available
Form CMS-P-0015A Health_Status	Form	Modified	Available
Form CMS-P-0015A Health_Insurance	Form	Modified	Available
Form CMS-P-0015A Questionaire	Form	Modified	Available
Form CMS-P-0015A Questionaire Missing Data	Form	Modified	Repair queued
Form CMS-P-0015A Expenditures	Form	Modified	Available
Form CMS-P-0015A Background_Questionnaire MIssing Data	Form	Modified	Available
Form CMS-P-0015A Background_Questionnaire	Form	Modified	Available
Form CMS-P-0015A Use of Health Services	Form	Modified	Available
Form CMS-P-0015A Residence History	Form	Modified	Available
Form CMS-P-0015A Residence History Missing Data	Form	Modified	Available
Form CMS-P-0015A Facility Screener	Form	Modified	Available
Form CMS-P-0015A Facility Showcards	Form	Modified	Available
Form CMS-P-0015A Showcards and Reference Cards	Form	Modified	Available
Form CMS-P-0015A Usual Source of Care	Form	Modified	Available
Form CMS-P-0015A Preventive Care	Form	Modified	Repair queued
Form CMS-P-0015A Beneficiary Knowledge	Form	Modified	Available
Form CMS-P-0015A Statement Cost Series	Form	Modified	Available
Form CMS-P-0015A Satisfaction Care	Form	Modified	Available
Form CMS-P-0015A Prescribed Medicine Utilization	Form	Modified	Available
Form CMS-P-0015A Outpatient Utilization	Form	Modified	Available
Form CMS-P-0015A Other Medical Expense	Form	Modified	Available
Form CMS-P-0015A No Statement Cost	Form	Modified	Available
Form CMS-P-0015A Nicotine Alcohol	Form	Modified	Available
Form CMS-P-0015A Medical Provider Utilzation	Form	Modified	Available
Form CMS-P-0015A Introduction	Form	Modified	Available
Form CMS-P-0015A Institutional Utilization	Form	Modified	Available
Form CMS-P-0015A Inpatient Utilization	Form	Modified	Available
Form CMS-P-0015A Income_and_ Assets	Form	Modified	Available
Form CMS-P-0015A Housing_Characteristics	Form	Modified	Available
Form CMS-P-0015A Home Health	Form	Modified	Available
Form CMS-P-0015A Health Insurance	Form	Modified	Available
Form CMS-P-0015A Emergency Utilization	Form	Modified	Available
Form CMS-P-0015A Drug Coverage	Form	Modified	Available
Form CMS-P-0015A Dental, Vision, and Hearing Care Utilization	Form	Modified	Available
Form CMS-P-0015A Chronic Pain	Form	Modified	Available
Form CMS-P-0015A Access to Care	Form	Modified	Available
Form CMS-P-0015A Post Statement Cost	Form	Modified	Available
Form CMS-P-0015A Mobility of Beneficiaries	Form	Modified	Available
Form CMS-P-0015A Enumeration Summary	Form	Modified	Available
Form CMS-P-0015A End Questionaire	Form	Modified	Available
Form CMS-P-0015A Demographic Income	Form	Modified	Available
Form CMS-P-0015A Cost Payment Summary	Form	Modified	Available
Form CMS-P-0015A Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Missing upstream
CMS-P-0015A_0938-0568_SSB_clean.docx	Supporting Statement B	Uploaded 2025-04-08	Available
CMS-P-0015A_0938-0568_SSB_clean.docx	Supporting Statement B	Uploaded 2025-04-08	Repair queued
CMS-P-0015A.Nonsubstantive Change Request Memo.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-04-08	Available
CMS-P-0015A.Nonsubstantive Change Request Memo.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-04-08	Repair queued
CMS-P-0015A.Supporting Statement Part A_Final.docx	Supporting Statement A	Uploaded 2025-04-08	Available
CMS-P-0015A.Supporting Statement Part A_Final.docx	Supporting Statement A	Uploaded 2025-04-08	Available
NonResponseLetterFraud.pdf	Supplementary Document	Uploaded 2024-07-11	Available
NonResponseLetterFraud.pdf	Supplementary Document	Uploaded 2024-07-11	Repair queued
Responses to Public Comments.docx	Supplementary Document	Uploaded 2024-07-11	Available
Responses to Public Comments.docx	Supplementary Document	Uploaded 2024-07-11	Repair queued
Fall 2023 Expanded Outreach Efforts.docx	Supplementary Document	Uploaded 2023-09-11	Available
Fall 2023 Expanded Outreach Efforts.docx	Supplementary Document	Uploaded 2023-09-11	Repair queued
Attachment 8. 2024 Testing Report.pdf	Supplementary Document	Uploaded 2023-06-26	Available
Attachment 8. 2024 Testing Report.pdf	Supplementary Document	Uploaded 2023-06-26	Repair queued
RedesignedComBrochure.pdf	Supplementary Document	Uploaded 2022-03-29	Available
RedesignedComBrochure.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
HCStatementGPLetter.pdf	Supplementary Document	Uploaded 2023-06-26	Available
HCStatementGPLetter.pdf	Supplementary Document	Uploaded 2023-06-26	Repair queued
FacThankYouLetter.pdf	Supplementary Document	Uploaded 2023-06-26	Available
FacThankYouLetter.pdf	Supplementary Document	Uploaded 2023-06-26	Repair queued
FacPrepInterviewLetter.pdf	Supplementary Document	Uploaded 2023-06-26	Available
FacPrepInterviewLetter.pdf	Supplementary Document	Uploaded 2023-06-26	Repair queued
FacAdvLetterBillOffices.pdf	Supplementary Document	Uploaded 2023-06-26	Available
FacAdvLetterBillOffices.pdf	Supplementary Document	Uploaded 2023-06-26	Available
ComLanguageInsert.pdf	Supplementary Document	Uploaded 2023-06-26	Repair queued
ComLanguageInsert.pdf	Supplementary Document	Uploaded 2023-06-26	Repair queued
BaseThankYouLetter.pdf	Supplementary Document	Uploaded 2023-06-26	Available
BaseThankYouLetter.pdf	Supplementary Document	Uploaded 2023-06-26	Repair queued
BaseFAQEnclosure.pdf	Supplementary Document	Uploaded 2023-06-26	Available
BaseFAQEnclosure.pdf	Supplementary Document	Uploaded 2023-06-26	Available
AdvLetterFAQEnclosure.pdf	Supplementary Document	Uploaded 2022-03-29	Available
AdvLetterFAQEnclosure.pdf	Supplementary Document	Uploaded 2022-03-29	Repair queued
ComAdvLetterCallUs.pdf	Supplementary Document	Uploaded 2023-06-26	Repair queued
ComAdvLetterCallUs.pdf	Supplementary Document	Uploaded 2023-06-26	Available
ComAdvLetterContactYou.pdf	Supplementary Document	Uploaded 2022-03-29	Available
ComAdvLetterContactYou.pdf	Supplementary Document	Uploaded 2022-03-29	Missing upstream
Attachment 7. 2023 Testing Report.pdf	Supplementary Document	Uploaded 2023-06-26	Available
Attachment 7. 2023 Testing Report.pdf	Supplementary Document	Uploaded 2023-06-26	Available
CMSThankYouLetter.pdf	Supplementary Document	Uploaded 2023-06-26	Available
CMSThankYouLetter.pdf	Supplementary Document	Uploaded 2023-06-26	Repair queued
Reminder Postcard_Phone.docx	Supplementary Document	Uploaded 2020-11-23	Available
Reminder Postcard_Phone.docx	Supplementary Document	Uploaded 2020-11-23	Available
ReminderPostcard.pdf	Supplementary Document	Uploaded 2023-06-26	Available
ReminderPostcard.pdf	Supplementary Document	Uploaded 2023-06-26	Available
Reminder Letter_Phone_English.docx	Supplementary Document	Uploaded 2020-11-23	Available
Reminder Letter_Phone_English.docx	Supplementary Document	Uploaded 2020-11-23	Repair queued
ReminderLetter.pdf	Supplementary Document	Uploaded 2023-06-26	Available
ReminderLetter.pdf	Supplementary Document	Uploaded 2023-06-26	Repair queued
NonResponseLetter.pdf	Supplementary Document	Uploaded 2023-06-26	Available
NonResponseLetter.pdf	Supplementary Document	Uploaded 2023-06-26	Missing upstream
IncomeandAssetsBrochure.pdf	Supplementary Document	Uploaded 2024-07-11	Available
IncomeandAssetsBrochure.pdf	Supplementary Document	Uploaded 2024-07-11	Repair queued
RedesignedComBrochure.pdf	Supplementary Document	Uploaded 2023-06-26	Available
RedesignedComBrochure.pdf	Supplementary Document	Uploaded 2023-06-26	Missing upstream
MCBSCommunityBrochure.pdf	Supplementary Document	Uploaded 2023-06-26	Available
MCBSCommunityBrochure.pdf	Supplementary Document	Uploaded 2023-06-26	Repair queued
CommunityAuthLetter.pdf	Supplementary Document	Uploaded 2023-06-26	Available
CommunityAuthLetter.pdf	Supplementary Document	Uploaded 2023-06-26	Available
ComAdvLetterContactYou.pdf	Supplementary Document	Uploaded 2023-06-26	Available
ComAdvLetterContactYou.pdf	Supplementary Document	Uploaded 2023-06-26	Missing upstream
MCBS Facility Brochure.pdf	Supplementary Document	Uploaded 2024-07-11	Available
MCBS Facility Brochure.pdf	Supplementary Document	Uploaded 2024-07-11	Repair queued
FacAdvanceLetter.pdf	Supplementary Document	Uploaded 2024-07-11	Available
FacAdvanceLetter.pdf	Supplementary Document	Uploaded 2024-07-11	Repair queued
Attachment 6. CAPI screenshots.pdf	Supplementary Document	Uploaded 2024-07-11	Available
Attachment 6. CAPI screenshots.pdf	Supplementary Document	Uploaded 2024-07-11	Repair queued
NextofKinForm.pdf	Supplementary Document	Uploaded 2024-07-11	Available
NextofKinForm.pdf	Supplementary Document	Uploaded 2024-07-11	Repair queued
ResConsentForm.pdf	Supplementary Document	Uploaded 2024-07-11	Available
ResConsentForm.pdf	Supplementary Document	Uploaded 2024-07-11	Available
HIPAALetter.pdf	Supplementary Document	Uploaded 2024-07-11	Available
HIPAALetter.pdf	Supplementary Document	Uploaded 2024-07-11	Repair queued
AtDoorSheet.pdf	Supplementary Document	Uploaded 2024-07-11	Available
AtDoorSheet.pdf	Supplementary Document	Uploaded 2024-07-11	Repair queued
MCBSCalendar.pdf	Supplementary Document	Uploaded 2024-07-11	Available
MCBSCalendar.pdf	Supplementary Document	Uploaded 2024-07-11	Repair queued
MCBSRespondentNewsletter.pdf	Supplementary Document	Uploaded 2023-06-26	Available
MCBSRespondentNewsletter.pdf	Supplementary Document	Uploaded 2023-06-26	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Interviewer_Remarks
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Health_Status
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Immunization
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Physical Measures Frequently Asked Questions (FAQ) Sheet
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Telemedicine Questionnaire
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Use of Health Services Section Specifications
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	COVID-19 Facility-Level Supplement
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	COVID-19 Questionnaire Specifications
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Physical_Measures
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	HFQ - Health Status and Functioning
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Cognitive Measures
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Health_Status
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Health_Insurance
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Questionaire
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Questionaire Missing Data
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Expenditures
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Background_Questionnaire MIssing Data
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Background_Questionnaire
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Use of Health Services
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Residence History
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Residence History Missing Data
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Facility Screener
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Facility Showcards
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Showcards and Reference Cards
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Usual Source of Care
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Preventive Care
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Beneficiary Knowledge
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Statement Cost Series
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Satisfaction Care
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Prescribed Medicine Utilization
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Outpatient Utilization
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Other Medical Expense
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	No Statement Cost
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Nicotine Alcohol
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Medical Provider Utilzation
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Introduction
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Institutional Utilization
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Inpatient Utilization
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Income_and_ Assets
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Housing_Characteristics
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Home Health
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Health Insurance
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Emergency Utilization
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Drug Coverage
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Dental, Vision, and Hearing Care Utilization
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Chronic Pain
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Access to Care
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Post Statement Cost
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Mobility of Beneficiaries
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Enumeration Summary
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	End Questionaire
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Demographic Income
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Cost Payment Summary
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified

ICR Details

OMB Control No: 0938-0568	ICR Reference No: 202504-0938-006
Status: Historical Active	Previous ICR Reference No: 202407-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No: OEDA
Title: Medicare Current Beneficiary Survey (MCBS) (CMS-P-0015A)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/17/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/09/2025
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2027	08/31/2027	08/31/2027
Responses	35,015	0	35,015
Time Burden (Hours)	35,206	0	35,344
Cost Burden (Dollars)	0	0	0

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Abstract: The Medicare Current Beneficiary Survey (MCBS) is a continuous, multipurpose survey of a nationally representative sample of aged, disabled, and institutionalized Medicare beneficiaries. MCBS, which is sponsored by the Centers for Medicare & Medicaid Services (CMS), is the only comprehensive source of information on the health status, health care use and expenditures, health insurance coverage, and socioeconomic and demographic characteristics of the entire spectrum of Medicare beneficiaries. The purpose of this revision is to seek approval for CMS to add new items related to beneficiary-centric provisions of the Inflation Reduction Act (IRA) of 2022 to the MCBS Community Questionnaire beginning in 2025 . The new items cover improved measures, streamlined content, and the addition of important IRA-related topics as requested by OMB in their terms of clearance specified in the approval of the 2024 MCBS.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 3021 Name of Law: Affordable Care Act
   PL: Pub.L. 108 - 173 723 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 32435	04/26/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 57901	07/16/2024
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, P-0015A, P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A, CMS-P-0015A	Cost Payment Summary ,   Demographic Income ,   End Questionaire ,   Enumeration Summary ,   Mobility of Beneficiaries ,   Post Statement Cost ,   Access to Care ,   Chronic Pain ,   Dental, Vision, and Hearing Care Utilization ,   Drug Coverage ,   Emergency Utilization ,   Health Insurance ,   Home Health ,   Housing_Characteristics ,   Income_and_ Assets ,   Inpatient Utilization ,   Institutional Utilization ,   Introduction ,   Medical Provider Utilzation ,   Nicotine Alcohol ,   No Statement Cost ,   Other Medical Expense ,   Outpatient Utilization ,   Prescribed Medicine Utilization ,   Satisfaction Care ,   Statement Cost Series ,   Beneficiary Knowledge ,   Preventive Care ,   Usual Source of Care ,   Showcards and Reference Cards ,   Facility Showcards ,   Facility Screener ,   Residence History Missing Data ,   Residence History ,   Use of Health Services ,   Background_Questionnaire ,   Background_Questionnaire MIssing Data ,   Expenditures ,   Questionaire Missing Data ,   Questionaire ,   Health_Insurance ,   Health_Status ,   Cognitive Measures ,   HFQ - Health Status and Functioning ,   Physical_Measures ,   COVID-19 Questionnaire Specifications ,   COVID-19 Facility-Level Supplement ,   Use of Health Services Section Specifications ,   Telemedicine Questionnaire ,   Physical Measures Frequently Asked Questions (FAQ) Sheet ,   Immunization ,   Health_Status ,   Interviewer_Remarks

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	35,015	35,015	0	0	0	0
Annual Time Burden (Hours)	35,206	35,344	0	-138	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The non-substantive changes included item deletions and revisions in the Demographics and Income Questionnaire (DIQ), which is administered in the Fall round during the respondent’s first MCBS interview (Baseline), and Item deletions in the Satisfaction with Care Questionnaire (SCQ), which is administered in the Fall round during the MCBS Baseline and Continuing interviews. These updates will result in a -138 hour decrease in burden for the current MCBS clearance.

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Annual Cost to Federal Government: $24,400,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/09/2025

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