Information Collection

Semi-structured interviews (State and local outreach partners)

IC 225197 under ICR 201701-0938-003 · OMB 0938-1339.

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

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 Agency Discretion
Annual Number of Responses for this IC	8	8
Annual IC Time Burden (Hours)	8	8
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.