Information Collection

Focus groups

IC 225195 under ICR 201701-0938-003 · OMB 0938-1339.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10634 Focus group: Subscribers Focus groups	Form
Form CMS-10634 Focus group: Subscribers (Spanish version) Focus groups	Form
Form CMS-10634 Focus Groups Call-In Script for Recruitment Focus groups	Form
Form CMS-10634 Consent Form for Focus Groups for Evaluating a Pilot Mobile Health Program Focus groups	Form
40400 OMB Appendix C2.pdf	Other-Text Messages to Recruit TEXT4
40400 OMB Appendix C4.pdf	Other-Pilot mHealth Focus Group: Rem
CMS-10634 Focus group: Subscribers 40400 OMB Appendix C1a [rev 01-20-2017 by OSORA PRA].pdf	Form
CMS-10634 Focus group: Subscribers (Spanish version) 40400 OMB Appendix C1b [rev 01-20-2017 by OSORA PRA].pdf	Form
CMS-10634 Focus Groups Call-In Script for Recruitment 40400 OMB Appendix C3.pdf	Form
CMS-10634 Consent Form for Focus Groups for Evaluating a Pilot Mob 40400 OMB Appendix C5.pdf	Form

IC Title:

Focus groups

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-10634	Focus group: Subscribers	40400 OMB Appendix C1a [rev 01-20-2017 by OSORA PRA].pdf	No	Paper Only
Form	CMS-10634	Focus group: Subscribers (Spanish version)	40400 OMB Appendix C1b [rev 01-20-2017 by OSORA PRA].pdf	No	Paper Only
Other-Text Messages to Recruit TEXT4BABY Subscribers for Focus Groups			40400 OMB Appendix C2.pdf	No	Printable Only
Form	CMS-10634	Focus Groups Call-In Script for Recruitment	40400 OMB Appendix C3.pdf	No	Fillable Fileable
Other-Pilot mHealth Focus Group: Reminder Call and Email Templates			40400 OMB Appendix C4.pdf	No	Printable Only
Form	CMS-10634	Consent Form for Focus Groups for Evaluating a Pilot Mobile Health Program	40400 OMB Appendix C5.pdf	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 96

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	96	96
Annual IC Time Burden (Hours)	163	163
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.