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Data Collection
Evaluation of the Graduate Nurse Education Demonstration Program (CMS-10467)
OMB: 0938-1212
IC ID: 207736
OMB.report
HHS/CMS
OMB 0938-1212
ICR 201601-0938-003
IC 207736
( )
Documents and Forms
Document Name
Document Type
Form CMS-10467
Data Collection
Form and Instruction
CMS-10467 Attachment 2: Qualitative Data Collection Protocol
Attach2QualData.pdf
Form and Instruction
CMS-10467 Qualitative Data Collection Protocols
2nd Passback CMS-10467 Evaluation of GNE Demo Attachment 1 Qualitative Protocols_Clean_TO CMS.docx
Form and Instruction
CMS-10467 Verbal Consent Statement
2nd Passback CMS-10467 Evaluation of GNE Demo Attachment 2 Verbal Consent.docx
Form and Instruction
Attach1CrossSumm.pdf
Attachment 1: Crosswalk
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Data Collection
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
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-10467
Attachment 2: Qualitative Data Collection Protocol
Attach2QualData.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10467
Verbal Consent Statement
2nd Passback CMS-10467 Evaluation of GNE Demo Attachment 2 Verbal Consent.docx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10467
Qualitative Data Collection Protocols
2nd Passback CMS-10467 Evaluation of GNE Demo Attachment 1 Qualitative Protocols_Clean_TO CMS.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Consumer Health and Safety
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
104
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
100 %
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
104
0
-486
0
0
590
Annual IC Time Burden (Hours)
802
0
102
0
0
700
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Attachment 1: Crosswalk
Attach1CrossSumm.pdf
01/21/2016
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.