Centenarian Project Development Worksheets: Face-to-Face Interview and Telephone Interview

Centenarian Project and Medicare Non-Utilzation Project Development Worksheets: Face-to-Face Interview; Telephone Interview

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0780 can be found here:

Documents and Forms

Document Name Document Type
Face to Face Worksheet - Revised Version.pdf Other-Interview Worksheet
Telephone Contact Worksheet - Revised Version.pdf Other-Interview Worksheet
Telephone Contact Worksheet - Current Version.pdf Telephone Contact Worksheet (current) IC Document
Face to Face Worksheet - Current Version.pdf Face to Face Worksheet (current) IC Document

Information Collection (IC) Details

IC Title:	Centenarian Project Development Worksheets: Face-to-Face Interview and Telephone Interview	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.204(b) 20 CFR 422.135

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Interview Worksheet			Face to Face Worksheet - Revised Version.pdf		Yes	No	Printable Only
Other-Interview Worksheet			Telephone Contact Worksheet - Revised Version.pdf		Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 22,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	22,000	22,000
Annual IC Time Burden (Hours)	5,500	5,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Telephone Contact Worksheet (current)	Telephone Contact Worksheet - Current Version.pdf	08/13/2013
Face to Face Worksheet (current)	Face to Face Worksheet - Current Version.pdf	08/13/2013

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