Information Collection

Beneficiary Focus Groups

IC 226870 under ICR 201705-0938-008 · OMB 0938-1332.

Documents and Forms

Documents and forms in this information collection
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

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 and Instruction	CMS-10625	Core Focus Group Moderatorâs 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 %

table that charts list of burden
	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

table that charts IC Documents
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.