Information Collection

Initial and Terminal Administration of the Survey

IC 199899 under ICR 201301-0938-003 · OMB 0938-1167.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1167 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10433 Initial and Terminal Administration of the Survey Form and Instruction
CMS-10403 CCTP -Spanish Version Appendix B CCTP items in Spanish.docx Form and Instruction
CMS-10403 CCTP_2nd_Admin_Participant_Exp_Survey CCTP_2nd_Admin_Participant_Exp_Survey_Draft_(3-12-12_glui)_Pilot_Test.docx Form and Instruction
CMS-10433 Appendix C_CCTP 1st Admin Participant Exp Survey Appendix C_CCTP 1st Admin Participant Exp Survey_Clean Version_Final.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Initial and Terminal Administration of the Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10433	Appendix C_CCTP 1st Admin Participant Exp Survey	Appendix C_CCTP 1st Admin Participant Exp Survey_Clean Version_Final.pdf	No		Paper Only
Form and Instruction	CMS-10403	CCTP -Spanish Version	Appendix B CCTP items in Spanish.docx	No	No	Paper Only
Form and Instruction	CMS-10403	CCTP_2nd_Admin_Participant_Exp_Survey	CCTP_2nd_Admin_Participant_Exp_Survey_Draft_(3-12-12_glui)_Pilot_Test.docx	No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 216,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	432,000	430,100	1,900
Annual IC Time Burden (Hours)	54,000	53,525	475
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.