Information Collection

Focus Group: Rounds 1 and 2

IC 251706 under ICR 202202-0938-005 · OMB 0938-1430.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10786 Focus Group: Rounds 1 and 2	Form and Instruction
Form CMS-10786 Focus Group Participant Questionnaire 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

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-10786				Yes	Yes	Fillable Fileable
Other-Crosswalk: Focus Group					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 %

table that charts list of burden
	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

table that charts IC Documents
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.

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