Information Collection

Peer Coach Assessment

IC 216841 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Additional Documentation - Peer Coach Questionnaire Email Language.docx	Instruction
Additional Documentation - Peer Coach Questionnaire Link.docx	Other-Link to Instrument
CMS-10567.Generic_Clearance_Submission_Template.doc CMS-10567.Generic_Clearance_Submission_Template	IC Document

IC Title:

Peer Coach Assessment

Agency IC Tracking Number:

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
Instruction			Additional Documentation - Peer Coach Questionnaire Email Language.docx		Yes	Yes	Fillable Fileable
Other-Link to Instrument			Additional Documentation - Peer Coach Questionnaire Link.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 36

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	36	36
Annual IC Time Burden (Hours)	6	6
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10567.Generic_Clearance_Submission_Template	CMS-10567.Generic_Clearance_Submission_Template.doc	06/02/2015

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