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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.