View Information Collection (IC)

View Information Collection (IC)

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 CMS-P-0015A Cost Payment Summary 2021_Cost_Payment_Summary_CPS.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Demographic Income 2020_Demographics_and_Income_DIQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A End Questionaire 2020_End_END.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Enumeration Summary 2019_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 interviewer Remarks 2019_Interviewer_Remarks_IRQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Mobility of Beneficiaries 2020_Mobility_of_Beneficiaries_MBQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Post Statement Cost 2019_Post_Statement_Cost_PSQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Access to Care 2020_Access_to_Care_ACQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Chronic Pain 2020_Chronic_Pain_CPQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Dental, Vision, and Hearing Care Utilization 2021_Dental_Vision_and_Hearing_Utilization_DVH.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Drug Coverage 2020_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 2020_Health_Insurance_HIQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Home Health 2020_Home_Health_Utilization_HHQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Housing_Characteristics 2021_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 2021_Inpatient_Utilization_IPQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Institutional Utilization 2020_Institutional_Utilization_IUQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Introduction 2020_Introduction_INQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Medical Provider Utilzation 2021_Medical_Provider_Utilization_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 2021_No_Statement_Cost_Series_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 2021_Prescribed_Medicine_Utilization_PMQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Satisfaction Care 2020_Satisfaction_with_Care_SCQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Statement Cost Series 2021_Statement_Cost_Series_STQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Beneficiary Knowledge 2021_Beneficiary_Knowledge_and_Information_Needs_KNQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Preventive Care 2021_Preventive_Care_PVQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Usual Source of Care 2021_Usual_Source_of_Care_USQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Showcards and Reference Cards 2021CommShowcards.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Facility Showcards 2019FacilityShowcards508.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Facility Screener Fac2019_Fac_Screener_FACSCREEN.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Residence History Missing Data Fac2019_Residence_Missing_RHM.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Residence History Fac2021_Residence_History_RH.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Use of Health Services Fac2020_Health_Status_HS.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 Fac2020_Facility_Missing_FQM.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Questionaire Fac2020_Facility_Quex_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 Fac2020_Health_Status_HS.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Health Status Attachment A - R88 HFQ.PDF Yes Yes Fillable Fileable
Form CMS-P-0015A Cognitive Measures 2020_Cognitive_Measures_CMQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Health_Status_and_Functioning 2021_Health_Status_and_Functioning_HFQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Physical_Measures 2021_Physical_Measures_PXQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A interviewer Remarks Fac2019_Interviewer_Remarks_IR.pdf Yes Yes Fillable Fileable
Form P-0015A COVID-19 Questionnaire Specifications 2021_COVID19_CVQ.pdf Yes Yes Fillable Fileable
Form P-0015A MCBS COVID-19 Winter 2021 Facility Supplement Fac2021_COVID19_CV.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) 54,426 0 10,063 0 0 44,363
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.