Information Collection

Semi-structured interviews (State and local outreach partners)

IC 225197 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 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

IC Title:

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	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 %

table that charts list of burden
	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

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.