Information Collection

Telephone survey

IC 225194 under ICR 201701-0938-003 · OMB 0938-1339.

Documents and Forms

Document Name Document Type
Form CMS-10634 Telephone survey Form
40400 OMB Appendix A2.pdf Other-Selection Letter (English and
40400 OMB Appendix A3.pdf Other-Selection Postcards (English a
CMS-10634 Medicaid Postpartum Survey 40400 OMB Appendix A1a [rev 01-20-2017 by OSORA PRA].pdf Form
CMS-10634 Medicaid Postpartum Survey (Spanish) 40400 OMB Appendix A1b [rev 01-20-2017 by OSORA PRA].pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Telephone survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10634	Medicaid Postpartum Survey	40400 OMB Appendix A1a [rev 01-20-2017 by OSORA PRA].pdf	Yes	Yes	Fillable Fileable
Form	CMS-10634	Medicaid Postpartum Survey (Spanish)	40400 OMB Appendix A1b [rev 01-20-2017 by OSORA PRA].pdf	Yes	Yes	Fillable Fileable
Other-Selection Letter (English and Spanish)			40400 OMB Appendix A2.pdf	No		Paper Only
Other-Selection Postcards (English and Spanish)			40400 OMB Appendix A3.pdf	No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,560	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,560	1,560
Annual IC Time Burden (Hours)	780	780
Annual IC Cost Burden (Dollars)	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.