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Semi-structured interviews (State and local outreach partners)
Evaluating a Pilot Mobile Health Program (CMS-10634)
OMB: 0938-1339
IC ID: 225197
OMB.report
HHS/CMS
OMB 0938-1339
ICR 201701-0938-003
IC 225197
( )
Documents and Forms
Document Name
Document Type
Form CMS-10634
Semi-structured interviews (State and local outreach partners)
Form
CMS-10634 Information Interview
40400 OMB Appendix B [rev 01-20-2107 by OSORA PRA].PDF
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Semi-structured interviews (State and local outreach partners)
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
Information Interview
40400 OMB Appendix B [rev 01-20-2107 by OSORA PRA].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:
8
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
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
8
0
8
0
0
0
Annual IC Time Burden (Hours)
8
0
8
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.
