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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.