Stakeholder Interview

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⚠️ Notice: This information collection may be referencing outdated material.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 Stakeholder Interview Form and Instruction
CMS-10477 Stakeholder interview appointment reminder Attachment_7b_Reminder_Text.pdf Form and Instruction
CMS-10477 Physician interview verbal consent script Attachment_2c_Consent_Form for Physicians.pdf Form and Instruction
CMS-10477 Stakeholder interview guide and consent form Attachment_7a_Interview Guide_Consent_Forms.pdf Form and Instruction
CMS-10477 Stakeholder interview scheduling script Attachment_7c_Scheduling_Script.pdf Form and Instruction
Attachment_2a_Physician_Interview_Email_Invitation.pdf Physician interview invitation note IC Document
Attachment_2b_Physician_Background_FAQ (revised).pdf Physician interview background/FAQ document IC Document

Information Collection (IC) Details

IC Title:	Stakeholder Interview	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	Stakeholder interview appointment reminder	Attachment_7b_Reminder_Text.pdf	No	No	Fillable Fileable
Form and Instruction	CMS-10477	Physician interview verbal consent script	Attachment_2c_Consent_Form for Physicians.pdf	No	No	Fillable Fileable
Form and Instruction	CMS-10477	Stakeholder interview guide and consent form	Attachment_7a_Interview Guide_Consent_Forms.pdf	No	No	Fillable Fileable
Form and Instruction	CMS-10477	Stakeholder interview scheduling script	Attachment_7c_Scheduling_Script.pdf	No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 45	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	45	45
Annual IC Time Burden (Hours)	23	23
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Physician interview invitation note	Attachment_2a_Physician_Interview_Email_Invitation.pdf	08/07/2013
Physician interview background/FAQ document	Attachment_2b_Physician_Background_FAQ (revised).pdf	08/07/2013

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