Information Collection

Medicare Health Care Quality (MHCQ) Demonstration Evaluation Focus Group and Interview Protocols--GHS

IC 209607 under ICR 201312-0938-005 · OMB 0938-1263.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10497 Medicare Health Care Quality (MHCQ) Demonstration Evaluation Focus Group and Interview Protocols--GHS	Form and Instruction
CMS-10497 GHS Beneficiary FG Recruitment Script GHS_Benef_Recruit_Script.pdf	Form and Instruction
CMS-10497 GHS Caregiver FG Recruitment Script GHS_Caregiver_Recruit_Script.pdf	Form and Instruction
CMS-10497 GHS FG Inform Consent GHS_Focus_Group_Inform_Consent.pdf	Form and Instruction
CMS-10497 GHS Beneficiaries Protocol CMS-10497.GHS Beneficiaries Protocol Revised - CLEAN (Version 06-10-14).pdf	Form and Instruction
CMS-10497 GHS Caregivers Protocol CMS-10497.GHS Caregivers Protocol Revised - CLEAN (Version 06-10-14).pdf	Form and Instruction

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-10497	GHS Beneficiary FG Recruitment Script	GHS_Benef_Recruit_Script.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10497	GHS Caregiver FG Recruitment Script	GHS_Caregiver_Recruit_Script.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10497	GHS FG Inform Consent	GHS_Focus_Group_Inform_Consent.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10497	GHS Beneficiaries Protocol	CMS-10497.GHS Beneficiaries Protocol Revised - CLEAN (Version 06-10-14).pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	CMS-10497	GHS Caregivers Protocol	CMS-10497.GHS Caregivers Protocol Revised - CLEAN (Version 06-10-14).pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12

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	12	12
Annual IC Time Burden (Hours)	36	36
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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