Program Participants Survey

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

OMB: 0938-1252

IC ID: 211403

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Program Participants Survey
 
No New
 
Voluntary
 

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

Health Health Care Services

 

24,814 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 24,814 0 24,814 0 0 0
Annual IC Time Burden (Hours) 10,296 0 10,296 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.
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