Information Collection

Program Participants Survey

IC 211403 under ICR 201404-0938-008 · OMB 0938-1252.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10509 Program Participants Survey	Form and Instruction
CMS-10509 Wellness Program Participant Surveys OMB_Wellness_Eval_Part_A_Attachment_3_Participant_Surveys_08122014_clean.docx	Form and Instruction
CMS-10509 In-Depth Interview Discussion Guide with Wellness Progra OMB_Wellness_Eval_Part_A_Attachment_4_Program_Interview_09052014_clean.docx	Form and Instruction
OMB_Draft_Wellness_Eval_Part_A_Attachment_5_Crosswalk_04102014.pdf Crosswalk	IC Document

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10509	In-Depth Interview Discussion Guide with Wellness Program Staff	OMB_Wellness_Eval_Part_A_Attachment_4_Program_Interview_09052014_clean.docx		No		Fillable Fileable
Form and Instruction	CMS-10509	Wellness Program Participant Surveys	OMB_Wellness_Eval_Part_A_Attachment_3_Participant_Surveys_08122014_clean.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 24,814

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	24,814	24,814
Annual IC Time Burden (Hours)	10,296	10,296
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	OMB_Draft_Wellness_Eval_Part_A_Attachment_5_Crosswalk_04102014.pdf	04/28/2014

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