Focus Groups

Healthy Indiana Program (HIP) 2.0 Beneficiary Focus Groups (CMS-10615)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1300 can be found here:

Documents and Forms

Document Name Document Type
7. FGRecruitmentScript_HIP 2.0_508_19July2016 (rev 09-28-2016).docx Other-Telephone Recruitment Script
9.FGModGuide_HIP2.0_508 03.13.18 clean.docx Other-CORE Focus Group Moderator’s G
CMS-10615 Participant Informed Consent 11. Focus Group Participant Informed Consent - HIP 2.0 [rev 07-21-2016 by OSORA PRA]508 (rev 09-29-2016).docx Form and Instruction
9.FGModGuide_HIP2.0_508 03.13.18 redline.docx Mooderator's Guide Crosswalk IC Document

Information Collection (IC) Details

IC Title:	Focus Groups	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Other-Telephone Recruitment Script			7. FGRecruitmentScript_HIP 2.0_508_19July2016 (rev 09-28-2016).docx	No	Fillable Printable
Form and Instruction	CMS-10615	Participant Informed Consent	11. Focus Group Participant Informed Consent - HIP 2.0 [rev 07-21-2016 by OSORA PRA]508 (rev 09-29-2016).docx	No	Fillable Fileable Signable
Other-CORE Focus Group Moderator’s Guide			9.FGModGuide_HIP2.0_508 03.13.18 clean.docx	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 80	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	Previously Approved
Annual Number of Responses for this IC	80	40	40
Annual IC Time Burden (Hours)	240	120	120
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Mooderator's Guide Crosswalk	9.FGModGuide_HIP2.0_508 03.13.18 redline.docx	03/30/2018

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