(CMS-10310) - Initial Screening

Consumer Research on Public Reporting of Hospital Outpatient Measures (CMS-10310)

Documents and Forms

Document Name Document Type
Form CMS-10310 (CMS-10310) - Initial Screening Form and Instruction
CMS-10310 Attachment B2_Screening Form_Caregivers CMS-10310.Attachment B2_Screening Form_Caregivers_REV.doc Form and Instruction
CMS-10310 Attachment B1_Screening Form_Consumers CMS-10310.Attachment B1_Screening Form_Consumers_REV.doc Form and Instruction
CMS-10310 Attachment B3_Screening Form_Professionals_REV CMS-10310.Attachment B3_Screening Form_Professionals_REV.doc Form and Instruction

Information Collection (IC) Details

IC Title:	(CMS-10310) - Initial Screening	Agency IC Tracking Number:

Is this a Common Form?		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10310	Attachment B2_Screening Form_Caregivers	CMS-10310.Attachment B2_Screening Form_Caregivers_REV.doc	Yes	No	Fillable Fileable
Form and Instruction	CMS-10310	Attachment B1_Screening Form_Consumers	CMS-10310.Attachment B1_Screening Form_Consumers_REV.doc	Yes	No	Fillable Fileable
Form and Instruction	CMS-10310	Attachment B3_Screening Form_Professionals_REV	CMS-10310.Attachment B3_Screening Form_Professionals_REV.doc	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 80	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	80	80
Annual IC Time Burden (Hours)	7	7
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.