Information Collection

Semi-Structured Interview

IC 235213 under ICR 201903-0938-004 · OMB 0938-1364.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10688 Semi-Structured Interview	Form and Instruction
CMS-10688 Home Health Agency Qualitative Interview Guide Attachment III - Home Health Interview Guide-CLEAN-Revised V2.pdf	Form and Instruction
Attachment IV - Interview Recruitment email or letter 508.pdf Interview Recruitment email or letter	IC Document
Attachment IX – Summary of Interview Content 508.pdf Summary of Interview Content	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-10688	Home Health Agency Qualitative Interview Guide	Attachment III - Home Health Interview Guide-CLEAN-Revised V2.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 30 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	60	60
Annual IC Cost Burden (Dollars)	4,748	4,748

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Interview Recruitment email or letter	Attachment IV - Interview Recruitment email or letter 508.pdf	03/07/2019
Summary of Interview Content	Attachment IX â Summary of Interview Content 508.pdf	03/07/2019

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