View Information Collection (IC)

View Information Collection (IC)

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

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-P-0015A Cost Payment Summary 2018_Cost_Payment_Summary_CPS.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Demographic Income 2018_Demographics_Income_DIQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A End Questionaire 2018_End_END.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Enumeration Summary 2018_Enumeration_Summary_ENS.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Home Health Summary 2018_Home_Health_Summary_HHS.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A nterviewer Remarks 2018_Interviewer_Remarks_IRQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Mobility of Beneficiaries 2018_Mobility_MBQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Post Statement Cost 2018_Post_Statement_Cost_PSQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Access to Care 2019_Access_to_Care_ACQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Chronic Pain 2019_Chronic_Pain_CPQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Dental, Vision, and Hearing Care Utilization 2019_Dental_Vision_Hearing_Util_DVH.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Drug Coverage 2019_Drug_Coverage_RXQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Emergency Utilization 2019_Emergency_Utilization_ERQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Health Insurance 2019_Health_Insurance_HIQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Home Health 2019_Home_Health_Util_HHQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Housing_Characteristics 2019_Housing_Charcs_HAQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Income_and_ Assets 2019_Income_and_ Assets_IAQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Inpatient Utilization 2019_Inpatient_Utilization_IPQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Institutional Utilization 2019_Institutional_Util_IUQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Introduction 2019_Introduction_INQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Medical Provider Utilzation 2019_Medical_Provider_Util_MPQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Nicotine Alcohol 2019_Nicotine_Alcohol_Use_NAQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A No Statement Cost 2019_No_Statement_Cost_NSQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Other Medical Expense 2019_Other_Medical_Expenses_OMQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Outpatient Utilization 2019_Outpatient_Util_OPQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Prescribed Medicine Utilization 2019_Prescribed_Med_Util_PMQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Satisfaction Care 2019_Satisfacation_Care_SCQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Statement Cost Series 2019_Statement_Cost_Series_STQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Beneficiary Knowledge 2020_Beneficiary_Knowledge_KNQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Preventive Care 2020_Preventive_Care_PVQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Usual Source of Care 2020_Usual_Source_Of_Care_USQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Showcards and Reference Cards 2020CommShowcards.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Facility Showcards 2018FacilityShowcards508.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Facility Screener Fac2018_Facility_Screener_FACSCREEN.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Residence History Missing Data Fac2018_Residence_History_Missing_Data_RHM.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Residence History Fac2018_Residence_History_RH.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Use of Health Services Fac2018_Use_of_Health_Services_US.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Background_Questionnaire Fac2019_Background_Questionnaire_BQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Background_Questionnaire MIssing Data Fac2019_Background_Questionnaire_Missing_Data_BQM.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Expenditures Fac2019_Expenditures_EX.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Questionaire Missing Data Fac2019_Facility_Questionnaire_Missing_Data_FQM.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Questionaire Fac2019_Facility_Questionnaire_FQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Health_Insurance Fac2019_Health_Insurance_IN.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Health_Status Fac2019_Health_Status_HS.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Health Status Attachment A - R88 HFQ.PDF Yes Yes Fillable Fileable

Health Health Care Services

 

35,998 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 35,998 0 0 0 0 35,998
Annual IC Time Burden (Hours) 42,610 0 0 0 0 42,610
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk Summary of Questionnaire Changes_OMB Passback.pdf 08/06/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.