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 2023_Demographics_Income_DIQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A End Questionaire 2023_End_END.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Enumeration Summary 2021_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 2021_Mobility_MBQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Post Statement Cost 2021_Post_Statement_Cost_PSQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Access to Care 2021_Access_To_Care_ACQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Chronic Pain 2023_Chronic_Pain_CPQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Dental, Vision, and Hearing Care Utilization 2023_Den_Vis_Hear_Care_Utl_DVH.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Drug Coverage 2021_Drug_Coverage_RXQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Emergency Utilization 2021_Emergency_Utilization_ERQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Health Insurance 2021_Health_Insurance_HIQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Home Health 2021_Home_Health_Util_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 2021_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 2021_Institutional_Util_IUQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Introduction 2023_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 2021_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 2021_Other_Medical_Expense_OMQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Outpatient Utilization 2021_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 2023_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 2023_Beneficiary_Knowledge_and_Information_Needs_KNQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Preventive Care 2023_Preventive_Care_PVQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Usual Source of Care 2023_Usual_Source_Of_Care_USQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Showcards and Reference Cards 2023CommShowcards508.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Facility Showcards 2021FacilityShowcards508.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Facility Screener Fac2021_Facility_Screener_FACSCREEN.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Residence History Missing Data Fac2021_Residence_Missing_RHM.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Residence History Fac2022_Residence_History_RH.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Use of Health Services Fac2021_Health_Status_HS.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Background_Questionnaire Fac2022_Background_BQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Background_Questionnaire MIssing Data Fac2021_Background_Missing_BQM.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Expenditures Fac2021_Expenditures_EX.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Questionaire Missing Data Fac2021_Facility_Missing_FQM.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Questionaire Fac2021_Facility_Quex_FQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Health_Insurance Fac2021_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 Cognitive Measures 2023_Cognitive_Measures_CMQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Health Status and Functioning Questionnaire Specification 2023_Health_Status_HFQ.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Physical_Measures 2023_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 2023_COVID_19_CVQ.pdf Yes Yes Fillable Fileable
Form P-0015A COVID-19 Facility-Level Supplement Fac2022_COVID_19_Fac_Supp_FC.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A CV-COVID-19 Beneficiary Supplement Fac2022_COVID_19_Bene_Supp_CV.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Use of Health Services Section Specifications Fac2022_Use_Health_Services_US.pdf Yes Yes Fillable Fileable
Form CMS-P-0015A Telemedicine Questionnaire 2023_Telemedicine_TLQ.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) 46,513 0 -7,913 0 0 54,426
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
No associated records found
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.