Information Collection

Stakeholder Interview

IC 208111 under ICR 201308-0938-006 · OMB 0938-1219.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

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-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 %

table that charts list of burden
	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

table that charts IC Documents
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.