Information Collection

Qualititative Data Collection

IC 207736 under ICR 201307-0938-004 · OMB 0938-1212.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1212 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10467 Qualititative Data Collection	Form and Instruction
CMS-10467 Consent Form for Key Informant Interviews and Focus Grou GNEKeyConsentFormCompliant.pdf	Form and Instruction
CMS-10467 Consent Form for Student Focus Groups GNEStudentConsentFormCompliant.pdf	Form and Instruction
CMS-10467 GNE Qualitative Data Collection Protocols for First In-P GNESteVist1ProtocolT1.pdf	Form and Instruction
CMS-10467 GNE Qualititave Data Collection Protocols for Interim Ch GNEInterimChckInProtocolT2.pdf	Form and Instruction
CMS-10467 GNE Qualitative Data Collection Protocols for Second In- GNESteVist2ProtocolT3.pdf	Form and Instruction

IC Title:

Qualititative Data Collection

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10467	Consent Form for Key Informant Interviews and Focus Groups	GNEKeyConsentFormCompliant.pdf	No	No	Paper Only
Form and Instruction	CMS-10467	Consent Form for Student Focus Groups	GNEStudentConsentFormCompliant.pdf	No	No	Paper Only
Form and Instruction	CMS-10467	GNE Qualitative Data Collection Protocols for First In-Person Site Visit	GNESteVist1ProtocolT1.pdf	No	No	Paper Only
Form and Instruction	CMS-10467	GNE Qualititave Data Collection Protocols for Interim Check-in	GNEInterimChckInProtocolT2.pdf	No	No	Paper Only
Form and Instruction	CMS-10467	GNE Qualitative Data Collection Protocols for Second In-Person Site Visit	GNESteVist2ProtocolT3.pdf	No	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 590

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 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	590	590
Annual IC Time Burden (Hours)	700	700
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.