Focus Groups

Healthy Indiana Program (HIP) 2.0 Beneficiaries Survey, Focus Groups, and Informational Interviews (CMS-10615)

⚠️ Notice: This information collection may be referencing outdated material.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
7. FGRecruitmentScript_HIP 2.0_508_19July2016 (rev 09-28-2016).docx Other-Telephone Recruitment Script
8. FGModGuide_HIP2.0_16July2016 v.2 (rev 09-28-2016).docx Other-CORE Focus Group Moderator’s G
CMS-10615 Participant Informed Consent 11. Focus Group Participant Informed Consent - HIP 2.0 [rev 07-21-2016 by OSORA PRA]508 (rev 09-29-2016).docx Form and Instruction
19. HIP2.0FocusGroupModeratorGuideCrosswalk_16July2016.xlsx Mooderator's Guide Crosswalk IC Document

Information Collection (IC) Details

IC Title:	Focus Groups	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	Available Electronically?	Electronic Capability
Other-Telephone Recruitment Script			7. FGRecruitmentScript_HIP 2.0_508_19July2016 (rev 09-28-2016).docx	No	Fillable Printable
Other-CORE Focus Group Moderator’s Guide			8. FGModGuide_HIP2.0_16July2016 v.2 (rev 09-28-2016).docx	No	Paper Only
Form and Instruction	CMS-10615	Participant Informed Consent	11. Focus Group Participant Informed Consent - HIP 2.0 [rev 07-21-2016 by OSORA PRA]508 (rev 09-29-2016).docx	No	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	120	120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Mooderator's Guide Crosswalk	19. HIP2.0FocusGroupModeratorGuideCrosswalk_16July2016.xlsx	07/20/2016

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