Information Collection

Focus Groups

IC 221370 under ICR 201807-0938-001 · OMB 0938-1300.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Focus Groups

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of 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 Moderatorâs 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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	80	80
Annual IC Time Burden (Hours)	240	240
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.