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

Medicare Health Care Quality (MHCQ) Demonstration Evaluation: Focus Group and Interview Protocols (CMS-10497)

Documents and Forms

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

Information Collection (IC) Details

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

	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

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.