Information Collection

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

IC 186977 under ICR 200810-0938-011 · OMB 0938-1064.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10270 Home Health Agencies Survey 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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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
Form and Instruction	CMS-10270				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: 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	570	570
Annual IC Time Burden (Hours)	285	285
Annual IC Cost Burden (Dollars)	0	0

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.

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