View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Medicare Disenrollee Survey - MA-PD (CMS-10316)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 423.156

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10316				No	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 123,662	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	61,831	0	1,831	0	0	60,000
Annual IC Time Burden (Hours)	16,694	0	-1,306	0	0	18,000
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 1 - PRE NOTIFICATION LETTERS		07/08/2013
Attachment 2 - SURVEY COVER LETTERS		07/08/2013
Crosswalk - MA PD		07/08/2013

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

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