Information Collection

Clinician Focus Groups on Telehealth and Social Determinants of Health (CMS-10820)

IC 257144 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10820 Clinician Focus Groups on Telehealth and Social Determinants of Health (CMS-10820)	Form and Instruction
CMS-10820 CMS-10820. CMS OBRHI_Clinician Focus Groups_Moderators G CMS-10820. CMS OBRHI_Clinician Focus Groups_Moderators Guide_Rev 20220803.docx	Form and Instruction
CMS-10820 CMS-10820. CMS OBRHI_Clinician Focus Groups_Moderators G CMS-10820. CMS OBRHI_Clinician Focus Groups_Moderators Guide_Rev 20220803.docx	Form and Instruction
CMS-10820 CMS OBRHI_Clinician Focus Groups_Eligibility Screener_Re CMS OBRHI_Clinician Focus Groups_Eligibility Screener_Rev 20221007.docx	Form and Instruction
CMS-10820 CMS OBRHI_Clinician Focus Groups_Eligibility Screener_Re CMS OBRHI_Clinician Focus Groups_Eligibility Screener_Rev 20221007.docx	Form and Instruction
CMS-10820.CMS OBRHI_Clinician Focus Groups_Supporting Statement_Rev 20221007 (1).docx CMS-10820.CMS OBRHI_Clinician Focus Groups Supporting Statement_Rev 20221007 (1)	IC Document
CMS-10820.CMS OBRHI_Clinician Focus Groups_Supporting Statement_Rev 20221007 (1).docx CMS-10820.CMS OBRHI_Clinician Focus Groups Supporting Statement_Rev 20221007 (1)	IC Document

IC Title:

Agency IC Tracking Number:

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-10820	CMS-10820. CMS OBRHI_Clinician Focus Groups_Moderators Guide_Rev 20220803	CMS-10820. CMS OBRHI_Clinician Focus Groups_Moderators Guide_Rev 20220803.docx		Yes	No	Printable Only
Form and Instruction	CMS-10820	CMS OBRHI_Clinician Focus Groups_Eligibility Screener_Rev 20221007.docx	CMS OBRHI_Clinician Focus Groups_Eligibility Screener_Rev 20221007.docx		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 148

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	148	148
Annual IC Time Burden (Hours)	73	73
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10820.CMS OBRHI_Clinician Focus Groups Supporting Statement_Rev 20221007 (1)	CMS-10820.CMS OBRHI_Clinician Focus Groups_Supporting Statement_Rev 20221007 (1).docx	11/28/2022

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