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Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-P-0015A Comm2017R77KNQ Comm2017R77KNQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A 2019CommShowcards_ForOMB30Day 2019CommShowcards_ForOMB30Day.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2017R78IAQ Comm2017R78IAQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2017R79DIQ Comm2017R79DIQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2017R79END Comm2017R79END.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2017R79ENS Comm2017R79ENS.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2017R79ERQ Comm2017R79ERQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2017R79HAQ Comm2017R79HAQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2017R79HHQ Comm2017R79HHQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2017R79HHS Comm2017R79HHS.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2017R79INQ Comm2017R79INQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2017R79IPQ Comm2017R79IPQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2017R79IUQ Comm2017R79IUQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2017R79MBQ Comm2017R79MBQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2017R79OPQ Comm2017R79OPQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2017R79PMQ Comm2017R79PMQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2017R79PSQ Comm2017R79PSQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2018R80ACQ Comm2018R80ACQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2018R80USQ Comm2018R80USQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2018R81RXQ Comm2018R81RXQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2018R82HFQ Comm2018R82HFQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2018R82NAQ Comm2018R82NAQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2018R82SCQ Comm2018R82SCQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2019R83CPS Comm2019R83CPS.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2019R83DVH Comm2019R83DVH.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2019R83HIQ Comm2019R83HIQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2019R83MPQ Comm2019R83MPQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2019R83NSQ Comm2019R83NSQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2019R83OMQ Comm2019R83OMQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2019R83STQ Comm2019R83STQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2019R84CPQ Comm2019R84CPQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Comm2019R85PVQ Comm2019R85PVQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Attachment 4 Facility Screener Attachment 4 Facility Screener.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A 2019FacilityShowcards_ForOMB 2019FacilityShowcards_ForOMB.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Fac2017R79RH Fac2017R79RH.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Fac2017R79RHM Fac2017R79RHM.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Fac2017R79US Fac2017R79US.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Fac2019R85BQ Fac2019R85BQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Fac2019R85BQM Fac2019R85BQM.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Fac2019R85EX Fac2019R85EX.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Fac2019R85FQ Fac2019R85FQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Fac2019R85FQM Fac2019R85FQM.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Fac2019R85HS Fac2019R85HS.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A Fac2019R85IN Fac2019R85IN.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-P-0015A OMB Facility Specs Guide OMB Facility Specs Guide.docx Yes Yes Fillable Fileable

Health Health Care Services

 

43,199 0
   
Individuals or Households
 
   100 %

  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 43,199 0 -6,451 0 0 49,650
Annual IC Time Burden (Hours) 44,165 0 -15,938 0 0 60,103
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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