Information Collection

Data Collection

IC 207736 under ICR 201601-0938-003 · OMB 0938-1212.

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	104	-486	590
Annual IC Time Burden (Hours)	802	102	700
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.