Evaluating Coverage to Care in Communities (CMS-10632)

OMB 0938-1342

The proposed evaluation is intended to achieve two separate but related goals. First, it will provide information that will support CMS OMH to maximize the impact of C2C at the local, state, and national levels. The evaluation will support selecting the best dissemination activities to maximize the spread of C2C, developing new messaging on preventive visits and primary care, and creating additional products to fill critical gaps. Second, findings from the evaluation will help CMS to assess whether and how C2C improves consumer health literacy and care utilization.

The latest form for Evaluating Coverage to Care in Communities (CMS-10632) expires 2020-09-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-10632 Consumer Survey Form and Instruction
Form CMS-10632 Consumer Survey Form and Instruction
Form CMS-10632 Partner Survey Form and Instruction
Form CMS-10632 Partner Survey Form and Instruction
CMS-10632_Non-sub_Change_Request_Memo 012623.docx Justification for No Material/Nonsubstantive Change
CMS-10632_Non-sub_Change_Request_Memo 012623.docx Justification for No Material/Nonsubstantive Change
CMS-10632_Supporting_Statement_B_clean_srs_012523.docx Supporting Statement B
CMS-10632_Supporting_Statement_B_clean_srs_012523.docx Supporting Statement B
CMS-10632_OMH_Supporting_Statement_A_clean_srs_012523.docx Supporting Statement A
CMS-10632_OMH_Supporting_Statement_A_clean_srs_012523.docx Supporting Statement A
CMS-10632.Appendix_E_Survey_Changes_srs_022221.pdf Supplementary Document
CMS-10632.Appendix_E_Survey_Changes_srs_022221.pdf Supplementary Document
Consumer Survey Form and Instruction
Consumer Survey Form and Instruction
Partner Survey Form and Instruction
Partner Survey Form and Instruction

All Historical Document Collections

202301-0938-018 Approved without change	No material or nonsubstantive change to a currently approved collection	2023-02-02
202105-0938-002 Approved with change	Reinstatement with change of a previously approved collection	2021-05-07
201704-0938-003 Approved without change	New collection (Request for a new OMB Control Number)	2017-04-12

OMB Details

Organizational Survey

Federal Enterprise Architecture: Health - Health Care Services

Form CMS-10632

Appendix A - Organization Survey: Informed Consent and Survey

Fillable Fileable

Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.