QualityNet Identity Management System (QIMS) Account Form

Forms and Documents

Document	Type	Status	Availability
Form CMS-10267 Training - Annual Security Awareness Power Point Training (Subsequent Years)	Form and Instruction	New	Repair queued
Form CMS-10267 Training - Annual Security Awareness Power Point Training (first year)	Form and Instruction	New	Repair queued
Form CMS-10267 QualityNet Identity Management System (QIMS) Account Form (Subsequent Years)	Form and Instruction	Modified	Repair queued
Form CMS-10267 QualityNet Identity Management System (QIMS) Account Form (First Year)	Form and Instruction	Modified	Repair queued
QIMS Self Registration Form screenshots 20100628.doc	Supplementary Document	Uploaded 2010-09-30	Available
Revisions to Form CMS 10267 - QIMS Account Form.docx	Supplementary Document	Uploaded 2010-09-30	Available
CMS-10267.REVISED - Supporting Statement Part A (clean).doc	Supporting Statement A	Uploaded 2011-02-07	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
194883	Training - Annual Security Awareness Power Point Training (Subsequent Years)	Form and Instruction	New
194882	Training - Annual Security Awareness Power Point Training (first year)	Form and Instruction	New
186127	QualityNet Identity Management System (QIMS) Account Form (Subsequent Years)	Form and Instruction	Modified
186126	QualityNet Identity Management System (QIMS) Account Form (First Year)	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1050	ICR Reference No: 201010-0938-003
Status: Historical Active	Previous ICR Reference No: 200903-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: QualityNet Identity Management System (QIMS) Account Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/14/2011
	Date Received in OIRA: 10/18/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2014	36 Months From Approved	05/31/2011
Responses	41,039	0	15,600
Time Burden (Hours)	68,520	0	7,800
Cost Burden (Dollars)	0	0	0

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Abstract: The QualityNet Identity Management System (QIMS) account registration form must be completed by any new persons needing access to Consolidated Renal Operations in a Web Enabled Network (CROWNWeb.) The 8,561 existing accounts owners will not have to reregister for new user accounts. The CROWNWeb user community is composed of CMS employees, ESRD Network Organization staff and dialysis facilities staff. The CROWNWeb system is the system used as the collection point of data necessary for entitlement of ESRD patients to Medicare benefits and Federal Government monitoring and assessing of quality and type of care provided to renal patients. The data collected in QIMS will provide the necessary security measures for creating and maintaining active CROWNWeb user accounts and collection of audit trail information required by the CMS Information Security Officers (ISSO).

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Authorizing Statute(s): US Code: 44 USC 35 Name of Law: Information Security
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 39696	07/12/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 57035	09/17/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

IC Title	Form No.	Form Name
QualityNet Identity Management System (QIMS) Account Form (First Year)	CMS-10267	CMS-10267.QIMS- Account Registration Form
QualityNet Identity Management System (QIMS) Account Form (Subsequent Years)	CMS-10267	CMS-10267.QIMS- Account Registration Form
Training - Annual Security Awareness Power Point Training (first year)	CMS-10267	CMS-10267.QIMS- Account Registration Form
Training - Annual Security Awareness Power Point Training (Subsequent Years)	CMS-10267	CMS-10267.QIMS- Account Registration Form

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	41,039	15,600	0	32,000	-6,561	0
Annual Time Burden (Hours)	68,520	7,800	0	64,000	-3,280	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: We have revised the collection instrument and adjusted the burden estimates.

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Annual Cost to Federal Government: $500,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/18/2010

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