Focus Group: Rounds 1 and 2

SUPPORT for Patients and Communities Act Section 1003 Demonstration Evaluation (CMS-10786)

Documents and Forms

Document Name Document Type
Form CMS-10786 Focus Group: Rounds 1 and 2 Form and Instruction
SUPPORTActFocusGroupCrosswalk.xlsx Other-Crosswalk: Focus Group
SUPPORTActFocusGroupCrosswalk.xlsx Other-Crosswalk: Focus Group
CMS-10786 Focus Group Participant Questionnaire focusgroup_SUPPORTAct1003.pdf Form and Instruction
CMS-10786 Focus Group Participant Questionnaire focusgroup_SUPPORTAct1003.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Focus Group: Rounds 1 and 2	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-10786	Focus Group Participant Questionnaire	focusgroup_SUPPORTAct1003.pdf		Yes	Yes	Fillable Fileable
Other-Crosswalk: Focus Group			SUPPORTActFocusGroupCrosswalk.xlsx		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 140	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	140	140
Annual IC Time Burden (Hours)	210	210
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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