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

Community First Choice Option Evaluation

Documents and Forms

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

Information Collection (IC) Details

IC Title:	State Discussion Protocol & Guide and Discussion Protocol for Stakeholder Focus Group	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	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 %

	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

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.