Information Collection

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

IC 216236 under ICR 201508-0938-014 · 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⚠️ Notice: This information collection may be referencing outdated material.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
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

IC Title:

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

Agency IC Tracking Number:

IC Status: Unchanged

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-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 %

table that charts list of burden
	Requested	Previously Approved
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

table that charts IC Documents
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.