Information Collection

MAPCP Demonstration: Focus Group Protocols

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	MAPCP Demonstration: Focus Group Protocols	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-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 %

	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

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.