Information Collection

Medicare Health Care Quality (MHCQ) Demonstration Evaluation Focus Group and Interview Protocols - MHS

IC 209608 under ICR 201312-0938-005 · OMB 0938-1263.

Documents and Forms

Document Name Document Type
Form CMS-10497 Medicare Health Care Quality (MHCQ) Demonstration Evaluation Focus Group and Interview Protocols - MHS Form and Instruction
CMS-10497 MHS Beneficiary Recruitment Script MHS_Benef_Recruitment_Script.pdf Form and Instruction
CMS-10497 MHS Caregiver FG Recruitment Script MHS_Caregiver_Recruit_Script.pdf Form and Instruction
CMS-10497 MHS Focus Group Inform Consent MHS_Focus_Group_Inform_Consent.pdf Form and Instruction
CMS-10497 MHS Caregivers Protocol CMS-10497.MHS Caregivers Protocol Revised - CLEAN (Version 06-10-14).pdf Form and Instruction
CMS-10497 MHS Beneficiaries Protocol CMS-10497.MHS Beneficiaries Protocol Revised - CLEAN (Version 06-10-14).pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Health Care Quality (MHCQ) Demonstration Evaluation Focus Group and Interview Protocols - MHS	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10497	MHS Beneficiary Recruitment Script	MHS_Benef_Recruitment_Script.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10497	MHS Caregiver FG Recruitment Script	MHS_Caregiver_Recruit_Script.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10497	MHS Focus Group Inform Consent	MHS_Focus_Group_Inform_Consent.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10497	MHS Caregivers Protocol	CMS-10497.MHS Caregivers Protocol Revised - CLEAN (Version 06-10-14).pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	CMS-10497	MHS Beneficiaries Protocol	CMS-10497.MHS Beneficiaries Protocol Revised - CLEAN (Version 06-10-14).pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 24	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	24	24
Annual IC Time Burden (Hours)	72	72
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.