OMB control number

Medicaid Incentives for Prevention of Chronic Diseases Evaluation (CMS-10477)

OMB 0938-1219 · HHS/CMS.

OMB 0938-1219

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CMS-10477 Yearly Admin Cost FormForm and Instruction
Form CMS-10477 Combined Administrative Cost Form - Informed ConsentForm and Instruction
Form CMS-10477 Survey_Spanish_new_cleanForm and Instruction
Form CMS-10477 CATI_Script_Spanish_new_cleanForm and Instruction
Form CMS-10477 Beneficiary survey phone follow-up for non-respondersForm and Instruction
Form CMS-10477 Beneficiary survey questionnaireForm and Instruction
Form CMS-10477 Consent_Forms_Spanish_new_cleanForm and Instruction
Form CMS-10477 Participant_Contact_Release_Forms_Spanish_new_cleanForm and Instruction
Form CMS-10477 Screener_Spanish_new_cleanForm and Instruction
Form CMS-10477 Focus group consent formForm and Instruction
Form CMS-10477 Participant contact release form for focus groupsForm and Instruction
Form CMS-10477 Discussion guide for focus groupsForm and Instruction
Form CMS-10477 Screener for focus group eligibilityForm and Instruction
Form CMS-10477 Stakeholder interview scheduling scriptForm and Instruction
Form CMS-10477 Stakeholder interview guide and consent formForm and Instruction
Form CMS-10477 Physician interview verbal consent scriptForm and Instruction
Form CMS-10477 Stakeholder interview appointment reminderForm and Instruction
Form CMS-10477 Clinic staff interview protocol and consentForm and Instruction
Form CMS-10477 State evaluator interview protocol and consentForm and Instruction
Form CMS-10477 Staff educator interview protocol and consentForm and Instruction
Form CMS-10477 Recruitment staff interview protocol and consentForm and Instruction
Form CMS-10477 Management staff interview protocol and consentForm and Instruction
MIPCDSupportStatementPartB.pdfSupporting Statement B
Attachment_6e_Reminder_Letter.pdf Supplementary Document
Attachment_6b_Survey_Cover_Letter.pdf Supplementary Document
Attachment_6a_Prenotification_Letter.pdf Supplementary Document
Attachment_4c_Recruitment_Flyer_Template.pdf Supplementary Document
Attachment_4f_Reminder_Email.pdf Supplementary Document
Attachment_2b_Physician_Background_FAQ (revised).pdf Supplementary Document
Attachment_2a_Physician_Interview_Email_Invitation.pdf Supplementary Document
Attachment_5b_Interview_Email_Invitation.pdf Supplementary Document
Attachment_5a_Background_FAQ.pdf Supplementary Document
MIPCD_Supp_State_Part_A_06_25_2014.docxSupporting Statement A
Administrative Cost Forms for MIPCD Form and Instruction
Administrative Cost Forms for MIPCD Form and Instruction
Beneficiary Satisfaction Survey Form and Instruction
Beneficiary Satisfaction Survey Form and Instruction
Beneficiary Satisfaction Survey Form and Instruction
Beneficiary Satisfaction Survey Form and Instruction
Focus Groups Form and Instruction
Focus Groups Form and Instruction
Focus Groups Form and Instruction
Focus Groups Form and Instruction
Focus Groups Form and Instruction
Focus Groups Form and Instruction
Focus Groups Form and Instruction
Stakeholder Interview Form and Instruction
Stakeholder Interview Form and Instruction
Stakeholder Interview Form and Instruction
Stakeholder Interview Form and Instruction
Site Visit Interviews Form and Instruction
Site Visit Interviews Form and Instruction
Site Visit Interviews Form and Instruction
Site Visit Interviews Form and Instruction
Site Visit Interviews Form and Instruction

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
201410-0938-001 Revision of a currently approved collection 2014-10-01 Approved without change
201308-0938-006 New collection (Request for a new OMB Control Number) 2013-08-07 Approved with change