Information Collection

Data Collection for the Nursing Home Value-Based Purchasing (NHVBP) Demonstration: BASELINE DATA

IC 182816 under ICR 200711-0938-010 · OMB 0938-1039.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1039 can be found here:

Documents and Forms

Document Name Document Type
CMS-10240 pra-attachments.doc Other-Application, Survey, Data Coll

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Data Collection for the Nursing Home Value-Based Purchasing (NHVBP) Demonstration: BASELINE DATA	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Application, Survey, Data Collection Form and Statistical Methods			CMS-10240 pra-attachments.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000	Number of Respondents for Small Entity: 200

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	31,950	31,950
Annual IC Cost Burden (Dollars)	400,000	400,000

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.