View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

CMS-10549.GenIC#3 - MCBS Cognitive Testing Self-Management Items
 
Unchanged
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10549.GenIC#3 Attachment C Screening Instrument CMS-10549#3 - Att. C Screening Instrument (OIRA Passback)_OEDA Reviewed..._.docx Yes No Fillable Fileable
Form and Instruction CMS-10549.GenIC#3 Attachment E Questionnaire CMS-10549.GenIC#3 - Att. E Questionnaire.docx Yes No Fillable Fileable

Health Health Care Services

 

41 0
   
Individuals or Households
 
   100 %

  Requested 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 41 0 0 0 0 41
Annual IC Time Burden (Hours) 22 0 0 0 0 22
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
CMS-10549.GenIC#3 - Att. B Recruitment Script CMS-10549.GenIC#3 - Att. B Recruitment Script.docx 09/26/2018
CMS-10549.GenIC#3 - Att. D Consent Form CMS-10549.GenIC#3 - Att. D Consent Form.docx 09/26/2018
CMS-10549.GenIC#3 - Att. F Showcard HF5 CMS-10549.GenIC#3 - Att. F Showcard HF5.pdf 09/26/2018
CMS-10549.GenIC#3 - Att. G Participant Fee Receipt CMS-10549.GenIC#3 - Att. G Participant Fee Receipt.docx 09/26/2018
CMS-10549.GenIC#3 - Att. H MCBS FAQ CMS-10549.GenIC#3 - Att. H MCBS FAQ.docx 09/26/2018
CMS-10549.GenIC#3 - Att. A Recruitment Flyers CMS-10549.GenIC#3 - Att. A Recruitment Flyers.docx 09/26/2018
CMS-10549.GenIC#3 - MCBS Cognitive Testing Self-Management Items - Mini Supporting Statement CMS-10549.GenIC#3 - MCBS Cognitive Testing Self-Management Items - Mini Supporting Statement.docx 09/26/2018
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.