Information Collection

State Discussion Protocol & Guide and Discussion Protocol for Stakeholder Focus Group

IC 211012 under ICR 201403-0938-017 · OMB 0938-1238.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10462 State Discussion Protocol & Guide and Discussion Protocol for Stakeholder Focus Group	Form
CMS-10462 Community First Choice State Discussion Protocol State Official - CFC State Discussion Protocol [rev 3-27-2014 by OSORA PRA].docx	Form
CMS-10462 Non-CFC State Discussion Guide State Official - Non-CFC State Discussion Protocol [rev 3-27-2014 by OSORA PRA].docx	Form
CMS-10462 Discussion Protocol for Stakeholder Focus Group CFC Stakeholder Discussion Protocol [rev 3-27-2014 by OSORA PRA].docx	Form

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	CMS-10462	Community First Choice State Discussion Protocol	State Official - CFC State Discussion Protocol [rev 3-27-2014 by OSORA PRA].docx	Yes	Yes	Fillable Printable
Form	CMS-10462	Non-CFC State Discussion Guide	State Official - Non-CFC State Discussion Protocol [rev 3-27-2014 by OSORA PRA].docx	Yes	Yes	Fillable Printable
Form	CMS-10462	Discussion Protocol for Stakeholder Focus Group	CFC Stakeholder Discussion Protocol [rev 3-27-2014 by OSORA PRA].docx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 28

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	28	28
Annual IC Time Burden (Hours)	105	105
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.