Information Collection

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

IC 209608 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 - MHS	Form and Instruction
CMS-10497 MHS Beneficiary Recruitment Script MHS_Benef_Recruitment_Script.pdf	Form and Instruction
CMS-10497 MHS Caregiver FG Recruitment Script MHS_Caregiver_Recruit_Script.pdf	Form and Instruction
CMS-10497 MHS Focus Group Inform Consent MHS_Focus_Group_Inform_Consent.pdf	Form and Instruction
CMS-10497 MHS Caregivers Protocol CMS-10497.MHS Caregivers Protocol Revised - CLEAN (Version 06-10-14).pdf	Form and Instruction
CMS-10497 MHS Beneficiaries Protocol CMS-10497.MHS Beneficiaries 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	MHS Beneficiary Recruitment Script	MHS_Benef_Recruitment_Script.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10497	MHS Caregiver FG Recruitment Script	MHS_Caregiver_Recruit_Script.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10497	MHS Focus Group Inform Consent	MHS_Focus_Group_Inform_Consent.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10497	MHS Caregivers Protocol	CMS-10497.MHS Caregivers Protocol Revised - CLEAN (Version 06-10-14).pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	CMS-10497	MHS Beneficiaries Protocol	CMS-10497.MHS Beneficiaries 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: 24

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	24	24
Annual IC Time Burden (Hours)	72	72
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.