Information Collection

Oral Health Illustration Survey (CMS-10864)

IC 282986 under ICR 202610-0938-001 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10864 Oral Health Survey Plan Oral Health Illustration Survey (CMS-10864)	Form and Instruction
Oral Health-Illustrations_CFRG.pptx	Other-Illustrations
CMS-10864 Oral Health Survey Plan CMS-10864.Oral Health Survey Plan (final).docx	Form and Instruction
CMS-10864.Fast Track - Oral Health Illustration Survey (final).docx CMS-10864.Fast Track - Oral Health Illustration Survey (final)	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-10864				Yes	No	Printable Only
Other-Illustrations					Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10864.Fast Track - Oral Health Illustration Survey (final)		10/13/2026

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

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