Site Visit Interviews

Medicaid Incentives for Prevention of Chronic Diseases Evaluation

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1219 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10477 Site Visit Interviews Form and Instruction
CMS-10477 Management staff interview protocol and consent Attachment_5c_SV_Management_Protocol_Consent_Form.pdf Form and Instruction
CMS-10477 Recruitment staff interview protocol and consent Attachment_5d_SV_Recruiter_Protocol_Consent_Form.pdf Form and Instruction
CMS-10477 Staff educator interview protocol and consent Attachment_5e_SV Educator_Protocol_Consent_Forms.pdf Form and Instruction
CMS-10477 State evaluator interview protocol and consent Attachment_5f_SV_Evaluator_Protocol_Consent Form.pdf Form and Instruction
CMS-10477 Clinic staff interview protocol and consent Attachment_5g_SV Clinic_Protocol_Consent_Forms.pdf Form and Instruction
Attachment_5a_Background_FAQ.pdf Site Visit Frequently Asked Questions IC Document
Attachment_5b_Interview_Email_Invitation.pdf Site visit interview invitation IC Document

Information Collection (IC) Details

IC Title:	Site Visit Interviews	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-10477	Management staff interview protocol and consent	Attachment_5c_SV_Management_Protocol_Consent_Form.pdf	No	No	Fillable Fileable
Form and Instruction	CMS-10477	Recruitment staff interview protocol and consent	Attachment_5d_SV_Recruiter_Protocol_Consent_Form.pdf	No	No	Fillable Fileable
Form and Instruction	CMS-10477	Staff educator interview protocol and consent	Attachment_5e_SV Educator_Protocol_Consent_Forms.pdf	No	No	Fillable Fileable
Form and Instruction	CMS-10477	State evaluator interview protocol and consent	Attachment_5f_SV_Evaluator_Protocol_Consent Form.pdf	No	No	Fillable Fileable
Form and Instruction	CMS-10477	Clinic staff interview protocol and consent	Attachment_5g_SV Clinic_Protocol_Consent_Forms.pdf	No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 10

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Site Visit Frequently Asked Questions	Attachment_5a_Background_FAQ.pdf	08/06/2013
Site visit interview invitation	Attachment_5b_Interview_Email_Invitation.pdf	08/06/2013

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