Beneficiary Focus Groups

Montana Health and Economic Livelihood Partnership (HELP) Federal Evaluation (CMS-10635)

Documents and Forms

Document Name Document Type
Form CMS-10625 Beneficiary Focus Groups Form and Instruction
MT_FGRecruitmentScript (OMB Passback 1)_rev_clean.docx Other-Telephone Recruitment Script
CMS-10625 Core Focus Group Moderator’s Guide FGModGuide_HELP_27Feb2017_508.docx Form and Instruction
Focus Group Participant Informed Consent_HELP-508_rev_clean.docx Participant Informed Consent Form IC Document

Information Collection (IC) Details

IC Title:	Beneficiary 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 and Instruction	CMS-10625	Core Focus Group Moderator’s Guide	FGModGuide_HELP_27Feb2017_508.docx		No		Paper Only
Other-Telephone Recruitment Script			MT_FGRecruitmentScript (OMB Passback 1)_rev_clean.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	180	180
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Participant Informed Consent Form	Focus Group Participant Informed Consent_HELP-508_rev_clean.docx	06/23/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.