Information Collection

Hospital Leadership Quality Assessment Tool (HLQAT) - Board Member

IC 187923 under ICR 200901-0938-010 · OMB 0938-1060.

Documents and Forms

Document Name Document Type
Form CMS-10272 Hospital Leadership Quality Assessment Tool (HLQAT) - Board Member Form and Instruction
CMS-10272 HLQAT Instrument CMS-10272.Instrument.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Hospital Leadership Quality Assessment Tool (HLQAT) - Board Member	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-10272	HLQAT Instrument	CMS-10272.Instrument.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: 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	6,000	6,000
Annual IC Time Burden (Hours)	5,220	5,220
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.