Information Collection

MAPCP Demonstration: Focus Group Protocols

IC 208628 under ICR 201309-0938-008 · OMB 0938-1224.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10479 MAPCP Demonstration: Focus Group Protocols	Form and Instruction
CMS-10479 Recruitment Script RecruitmentScript.pdf	Form and Instruction
CMS-10479 Focus Group Guide for Beneficiaries FG-beneficiaries_7-19-13.pdf	Form and Instruction
CMS-10479 Focus Group Guide for Caregivers of Beneficiaries FG-caregivers_7-19-13.pdf	Form and Instruction
CMS-10479 Informed Consent to Participate in Research for Benefici InformedConsent_FINAL.pdf	Form and Instruction
BeneFG-RecruitLetter_Medicaid.pdf Beneficiary Focus Group Recruitment Letter (Medicaid)	IC Document
BeneFG-RecruitLetter_Medicare.pdf Beneficiary Focus Group Recruitment Letter (Medicare or Medicare-Medicaid Enrollee)	IC Document
FR60day_CMSresp8-2-13crosswalk.pdf Crosswalk	IC Document

IC Title:

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-10479	Recruitment Script	RecruitmentScript.pdf	No	No	Fillable Fileable
Form and Instruction	CMS-10479	Focus Group Guide for Beneficiaries	FG-beneficiaries_7-19-13.pdf	No	No	Fillable Fileable
Form and Instruction	CMS-10479	Focus Group Guide for Caregivers of Beneficiaries	FG-caregivers_7-19-13.pdf	No	No	Fillable Fileable
Form and Instruction	CMS-10479	Informed Consent to Participate in Research for Beneficiaries and Caregivers	InformedConsent_FINAL.pdf	No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 768

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	384	384
Annual IC Time Burden (Hours)	1,152	1,152
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Beneficiary Focus Group Recruitment Letter (Medicaid)	BeneFG-RecruitLetter_Medicaid.pdf	09/09/2013
Beneficiary Focus Group Recruitment Letter (Medicare or Medicare-Medicaid Enrollee)	BeneFG-RecruitLetter_Medicare.pdf	09/09/2013
Crosswalk	FR60day_CMSresp8-2-13crosswalk.pdf	09/09/2013

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