View Information Collection (IC)

View Information Collection (IC)

IC Title:	Interview Guide	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 423.32 42 CFR 422.60 42 CFR 422.50

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10816	Informed Consent	Attachment D - Informed Consent Form CMS-10816_508.pdf		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10816	Cognitive Interview Protocol	DRAFT Revised Instrument 1- Cognitive Interview Protocol (English)_3.09.23 - CLEAN .docx		Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Medicare Advantage Prescription Drug (MARx)	FR Citation: 83 FR 6591

Number of Respondents: 120	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 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	120	0	0	120	0	0
Annual IC Time Burden (Hours)	84	0	0	84	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Person consulted	Attachment E - Persons Consulted CMS-10816_508.pdf	11/25/2022
Analysis Plan	Attachment F Analysis Plan CMS-10816_508.pdf	11/25/2022

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