Evaluation of the Home Health Pay for Performance Demonstration (CMS-10270)

Evaluation of the Home Health Pay for Performance Demonstration: Survey instrument

Documents and Forms

Document Name Document Type
Form CMS-10270 Evaluation of the Home Health Pay for Performance Demonstration (CMS-10270) Form and Instruction
CMS-10270 Home Health Agencies Survey CMS-10270. Part A Appendix_final.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Evaluation of the Home Health Pay for Performance Demonstration (CMS-10270)	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10270	Home Health Agencies Survey	CMS-10270. Part A Appendix_final.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 570	Number of Respondents for Small Entity: 540

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	570	570
Annual IC Time Burden (Hours)	285	285
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.