Information Collection

(CMS-10560) Focus Groups to Inform the Development of a Marketplace Dental Survey

IC 216236 under ICR 201412-0938-006 · OMB 0938-1185.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1185 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10560 (CMS-10560) Focus Groups to Inform the Development of a Marketplace Dental Survey Form and Instruction
CMS-10560 Focus Group Eligibility Screener, Consent form and Proto Generic Clearance Submission_Marketplace Dental Survey Focus Group0421.docx Form and Instruction
Generic Clearance Submission FORM_Marketplace Dental Survey Focus0421.doc Marketplace Dental Survey Form IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	(CMS-10560) Focus Groups to Inform the Development of a Marketplace Dental Survey	Agency IC Tracking Number:

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-10560	Focus Group Eligibility Screener, Consent form and Protocol	Generic Clearance Submission_Marketplace Dental Survey Focus Group0421.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Master Demonstration, Evaluation, and Research Studies (DERS	FR Citation: 72 FR 19705

Number of Respondents: 36	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	36	36
Annual IC Time Burden (Hours)	72	72
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Marketplace Dental Survey Form	Generic Clearance Submission FORM_Marketplace Dental Survey Focus0421.doc	04/22/2015

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