Program Participants Survey

Prospective Evaluation of Evidence-Based Community Wellness and Prevention Programs (CMS-10509)

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Program Participants Survey	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	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 %

	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

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.