View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Oral Health Illustration Survey (CMS-10864)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Illustrations			Oral Health-Illustrations_CFRG.pptx		Yes	No	Printable Only
Form and Instruction	CMS-10864	Oral Health Survey Plan	CMS-10864.Oral Health Survey Plan (final).docx		Yes	No	Printable Only

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: 100	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	100	0	100	0	0	0
Annual IC Time Burden (Hours)	17	0	17	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10864.Fast Track - Oral Health Illustration Survey (final)	CMS-10864.Fast Track - Oral Health Illustration Survey (final).docx	07/13/2023

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