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Focus groups
Evaluating a Pilot Mobile Health Program (CMS-10634)
OMB: 0938-1339
IC ID: 225195
OMB.report
HHS/CMS
OMB 0938-1339
ICR 201701-0938-003
IC 225195
( )
Documents and Forms
Document Name
Document Type
Form CMS-10634
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
Information Collection (IC) Details
View Information Collection (IC)
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:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted 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
Federal Enterprise Architecture Business Reference Module
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 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
96
0
96
0
0
0
Annual IC Time Burden (Hours)
163
0
163
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
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.