Home and Community-Based Services (HCBS) Experience Survey

Forms and Documents

Document Name	Status
Form CMS-10389 Home and Community-Based Services (HCBS) Experience Survey Form and Instruction	Modified
Supporting Statement - Part B-HCBS_1_31_13_clean copy.docx.docx Supporting Statement B	2013-02-01
Supporting Statement - Part A-HCBS_1_14_13_clean copy.docx Supporting Statement A	2013-02-01

IC Document Collections

IC ID	Document Title	Status
203499	Home and Community-Based Services (HCBS) Experience Survey Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1186	ICR Reference No: 201302-0938-001
Status: Historical Active	Previous ICR Reference No: 201207-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No: 18716
Title: Home and Community-Based Services (HCBS) Experience Survey
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/04/2013
	Date Received in OIRA: 02/04/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2016	36 Months From Approved
Responses	18,000	0	0
Time Burden (Hours)	9,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The goal of this survey is to provide standard performance metrics for HCBS programs that are applicable to all populations served by these programs, including people with physical disabilities, cognitive disabilities, intellectual impairments, and/or disabilities due to mental illness.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 2701 Name of Law: Affordable Care Act
   US Code: 42 USC 2701 Name of Law: Adult Quality Health Measures
   US Code: 42 USC 3011 Name of Law: National Quality Strategy
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 2701 Name of Law: Affordable Care Act
US Code: 42 USC 2701 Name of Law: Adult Quality Health Measures
US Code: 42 USC 3011 Name of Law: National Quality Strategy

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 29644	05/18/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 43288	07/24/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Home and Community-Based Services (HCBS) Experience Survey	CMS-10389, CMS-10389, CMS-10389	Survey Instruments ,   Consent Form (Spanish) ,   Consent Form (English)

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	18,000	0	18,000	0	0	0
Annual Time Burden (Hours)	9,000	0	9,000	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection.

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Annual Cost to Federal Government: $272,282

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/01/2013

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