Information Collection

Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey

IC 220696 under ICR 201603-0938-014 · OMB 0938-1300.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1300 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10615 Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey	Form
TestingRecruitmentScripts_18March2016.docx	Other-Recruitment Script
CMS-10615 Alternate Policy Survey Question Alternate Policy Survey Question Approach_final_18March2016.docx	Form
CMS-10615 Debriefing Script - Alternate Policy Survey Questions AlternatePolicySurveyQs_DebriefingScript_18March2016.docx	Form and Instruction
CMS-10615 Consent Form Consent for Release Form_18March2016.doc	Form
CMS-10615 Debriefing Script - Disenrolelee Lockout Survey DisenrolleeLockoutSurvey_DebriefingScript_18March2016.docx	Form and Instruction
CMS-10615 Debriefing Script - Enrollee Survey EnrolleeSurvey_DebriefingScript_18March2016.docx	Form and Instruction
CMS-10615 Disenrollee Lockout Survey HIPDisenrolleeLockoutSurvey_testing_emergency 18March2016.docx	Form
CMS-10615 Enrollee Survey HIPEnrolleeSurvey_testing_emergency 18March2016.docx	Form
CMS-10615 New Enrollee Survey HIPNewEnrolleeSurvey_testing_emergency 18March2016.docx	Form
CMS-10615 Debriefing Script - New Enrollee Survey NewEnrolleeSurvey_DebriefingScript_18March2016.docx	Form and Instruction

IC Title:

Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey

Agency IC Tracking Number:

Is this a Common Form? No

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	Available Electronically?	Electronic Capability
Form	CMS-10615	Alternate Policy Survey Question	Alternate Policy Survey Question Approach_final_18March2016.docx	No	Paper Only
Form and Instruction	CMS-10615	Debriefing Script - Alternate Policy Survey Questions	AlternatePolicySurveyQs_DebriefingScript_18March2016.docx	No	Fillable Printable
Form	CMS-10615	Consent Form	Consent for Release Form_18March2016.doc	No	Fillable Printable
Form and Instruction	CMS-10615	Debriefing Script - Disenrolelee Lockout Survey	DisenrolleeLockoutSurvey_DebriefingScript_18March2016.docx	No	Fillable Printable
Form and Instruction	CMS-10615	Debriefing Script - Enrollee Survey	EnrolleeSurvey_DebriefingScript_18March2016.docx	No	Fillable Printable
Form	CMS-10615	Disenrollee Lockout Survey	HIPDisenrolleeLockoutSurvey_testing_emergency 18March2016.docx	No	Fillable Printable
Form	CMS-10615	Enrollee Survey	HIPEnrolleeSurvey_testing_emergency 18March2016.docx	No	Fillable Printable
Form	CMS-10615	New Enrollee Survey	HIPNewEnrolleeSurvey_testing_emergency 18March2016.docx	No	Fillable Printable
Other-Recruitment Script			TestingRecruitmentScripts_18March2016.docx	No	Paper Only
Form and Instruction	CMS-10615	Debriefing Script - New Enrollee Survey	NewEnrolleeSurvey_DebriefingScript_18March2016.docx	No	Fillable Printable

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)	36	36
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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