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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-P-0015A Debt Questionaire	Form	Modified	Available
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 Telemedicine Questionnaire	Form	Modified	Available
Form CMS-P-0015A Use of Health Services Section Specifications	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_Insurance	Form	Modified	Available
Form CMS-P-0015A Questionaire	Form	Modified	Repair queued
Form CMS-P-0015A Questionaire Missing Data	Form	Modified	Available
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 Health_Status	Form	Modified	Available
Form CMS-P-0015A Residence History	Form	Modified	Repair queued
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	Repair queued
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	Repair queued
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	Repair queued
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	Repair queued
CMS-P-0015A 0938-0568_SSA.docx	Supporting Statement A	Uploaded 2025-11-21	Available
CMS-P-0015A 0938-0568_SSA.docx	Supporting Statement A	Uploaded 2025-11-21	Repair queued
CMS-P-0015A_0938-0568_SSB.docx	Supporting Statement B	Uploaded 2025-11-19	Repair queued
CMS-P-0015A_0938-0568_SSB.docx	Supporting Statement B	Uploaded 2025-11-19	Repair queued
2026 Full Clearance 30-Day Crosswalk.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
2026 Full Clearance 30-Day Crosswalk.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
CMS-2025-0337-DRAFT-0001 (1).html.pdf	Public Comments	Uploaded 2025-09-03	Available
mapresearch.pdf	Public Comments	Uploaded 2025-09-12	Repair queued
Justice in Aging.pdf	Public Comments	Uploaded 2025-09-12	Repair queued
Responses to Public Comments.docx	Supplementary Document	Uploaded 2025-11-19	Available
Responses to Public Comments.docx	Supplementary Document	Uploaded 2025-11-19	Repair queued
NonResponseLetterFraud.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
NonResponseLetterFraud.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
HCStatementGPLetter.pdf	Supplementary Document	Uploaded 2025-11-19	Available
HCStatementGPLetter.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
FacThankYouLetter.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
FacThankYouLetter.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
FacPrepInterviewLetter.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
FacPrepInterviewLetter.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
FacAdvLetterBillOffices.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
FacAdvLetterBillOffices.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
ComLanguageInsert.pdf	Supplementary Document	Uploaded 2025-11-19	Available
ComLanguageInsert.pdf	Supplementary Document	Uploaded 2025-11-19	Missing upstream
BaseThankYouLetter.pdf	Supplementary Document	Uploaded 2025-11-19	Available
BaseThankYouLetter.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
BaseFAQEnclosure.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
BaseFAQEnclosure.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
MCBSFAQ.pdf	Supplementary Document	Uploaded 2025-11-19	Available
MCBSFAQ.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
ComAdvLetterCallUs.pdf	Supplementary Document	Uploaded 2025-11-19	Available
ComAdvLetterCallUs.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
CMSThankYouLetter.pdf	Supplementary Document	Uploaded 2025-11-19	Available
CMSThankYouLetter.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
ReminderPostcard.pdf	Supplementary Document	Uploaded 2025-11-19	Available
ReminderPostcard.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
ReminderLetter.pdf	Supplementary Document	Uploaded 2025-11-19	Available
ReminderLetter.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
NonResponseLetter.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
NonResponseLetter.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
IncomeandAssetsBrochure.pdf	Supplementary Document	Uploaded 2025-11-19	Available
IncomeandAssetsBrochure.pdf	Supplementary Document	Uploaded 2025-11-19	Missing upstream
RedesignedComBrochure.pdf	Supplementary Document	Uploaded 2025-11-19	Available
RedesignedComBrochure.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
MCBSCommunityBrochure.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
MCBSCommunityBrochure.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
ComAuthLetter.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
ComAuthLetter.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
ComAdvLetterContactYou.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
ComAdvLetterContactYou.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
MCBS Facility Brochure.pdf	Supplementary Document	Uploaded 2025-11-19	Available
MCBS Facility Brochure.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
FacAdvanceLetter.pdf	Supplementary Document	Uploaded 2025-11-19	Available
FacAdvanceLetter.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
Attachment 6. CAPI screenshots.pdf	Supplementary Document	Uploaded 2025-11-19	Available
Attachment 6. CAPI screenshots.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
NextofKinForm.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
NextofKinForm.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
ResConsentForm.pdf	Supplementary Document	Uploaded 2025-11-19	Available
ResConsentForm.pdf	Supplementary Document	Uploaded 2025-11-19	Repair queued
HIPAALetter.pdf	Supplementary Document	Uploaded 2025-11-18	Available
HIPAALetter.pdf	Supplementary Document	Uploaded 2025-11-18	Repair queued
MCBSCalendar.pdf	Supplementary Document	Uploaded 2025-11-18	Available
MCBSCalendar.pdf	Supplementary Document	Uploaded 2025-11-18	Repair queued
MCBSRespondentNewsletter.pdf	Supplementary Document	Uploaded 2025-11-18	Repair queued
MCBSRespondentNewsletter.pdf	Supplementary Document	Uploaded 2025-11-18	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8171	Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)	Form	Modified	Debt Questionaire
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	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	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_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	Health_Status
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: 202511-0938-005
Status: Active	Previous ICR Reference No: 202504-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: OEDA
Title: Medicare Current Beneficiary Survey (MCBS) (CMS-P-0015A)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/06/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/21/2025
Terms of Clearance: Prior to the re-submission of the information collection (IC) “Medicare Current Beneficiary Survey (MCBS)” (0938-0568), the agency will assess its respondent burden. This assessment will be guided by the principles and priorities set forth in the Executive Order 14192 title "Unleashing Prosperity Through Deregulation" (January 21, 2025) https://www.whitehouse.gov/presidential-actions/2025/01/unleashing-prosperity-through-deregulation/. The assessment will inform and be integrated in the agency’s next extension or revision of this information collection. Also, the agency will offset any new additional burden created by new forthcoming supplemental information collections that use the MCBS (0938-0568) panel.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2029	36 Months From Approved	08/31/2027
Responses	35,015	0	35,015
Time Burden (Hours)	32,258	0	35,206
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 on sleep apnea, thyroid disease, and bowel disease, remove content that is no longer relevant to the goals of the survey, and update existing content to better meet the policy needs of CMS and stakeholders. To ensure the sustainability of the survey and to maintain a reasonable level of respondent burden, it is necessary to routinely review MCBS survey content and remove items that are no longer as relevant to the policy landscape or which are no longer performing well. The requested deletions are a result of a content reduction process that CMS developed in 2024 and is currently using to review MCBS survey content in the Community and Facility instruments. The goals of this process are three-fold: 1) to promote efficiency by streamlining the questionnaire and reducing respondent burden; 2) to continuously assess utility of information collected by the MCBS and remove questions that are no longer relevant, and 3) to maintain the production of high-quality data by removing content that is no longer performing well. For this full clearance revision, CMS has used the content reduction process to identify items that a) are low performing due to difficulty of administration or data quality issues, b) are no longer needed at the same frequency of administration, c) require updated question text or response options, or d) no longer match the existing healthcare landscape or require further evaluation.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 723 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act
   PL: Pub.L. 111 - 148 3021 Name of Law: Affordable Care 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:
	90 FR 31207	07/14/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 52675	11/21/2025
Did the Agency receive public comments on this ICR? Yes

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

table that charts list of burden

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, 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 ,   Health_Status ,   Background_Questionnaire ,   Background_Questionnaire MIssing Data ,   Expenditures ,   Questionaire Missing Data ,   Questionaire ,   Health_Insurance ,   Cognitive Measures ,   HFQ - Health Status and Functioning ,   Use of Health Services Section Specifications ,   Telemedicine Questionnaire ,   Immunization ,   Health_Status ,   Interviewer_Remarks ,   Debt Questionaire

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ICR Summary of Burden

table that charts list 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)	32,258	35,206	0	-2,948	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: Burden has decreased due to the removal of 209 items and the revision of 46 items. As a result, the total burden has decreased from 35,206 in the currently approved clearance to 32,258. This is a net decrease of 2,948 burden hours annually.

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Annual Cost to Federal Government: $22,000,000

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: 11/21/2025

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