Information Collection

Data Collection for the Nursing Home Value-Based Purchasing (NHVBP) Demonstration: ONGOING DATA (CMS-10240)

IC 182817 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⚠️ Notice: This information collection may be referencing outdated material.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
CMS-10240 nhvbp-paperburden.xls CMS-10240 nhvbp-paperburden	IC Document

IC Title:

Data Collection for the Nursing Home Value-Based Purchasing (NHVBP) Demonstration: ONGOING DATA (CMS-10240)

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, 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: 250

Number of Respondents for Small Entity: 50

Affected Public: Private Sector

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

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)	17,220	17,220
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10240 nhvbp-paperburden	CMS-10240 nhvbp-paperburden.xls	10/11/2007

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