Information Collection

Nursing Home survey

IC 192514 under ICR 201004-0938-003 · OMB 0938-1104.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10294 Nursing Home survey	Form and Instruction
CMS-10294 CMS-10294.QIO Surveys and Letters CMS-10294.QIO Surveys and Letters.pdf	Form and Instruction

IC Title:

Nursing Home survey

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-10294	CMS-10294.QIO Surveys and Letters	CMS-10294.QIO Surveys and Letters.pdf		No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,250

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	1,250	1,250
Annual IC Time Burden (Hours)	413	413
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.