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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
CMS-10240 pra-attachments.doc	Other-Application, Survey, Data Coll

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:

table that charts list of 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 %

table that charts list of burden
	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

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.