Information Collection

Survey

IC 198380 under ICR 201107-0938-001 · OMB 0938-1149.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1149 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10381 Survey Form
CMS-10381 CMS-10381.Appendix C Respondent Letters Version 5010 ICD CMS-10381.Appendix C Respondent Letters Version 5010 ICD10 Readiness Assessment.pdf Form
CMS-10381 CMS-10381.Appendix D Version 5010 ICD-10 Industry Readin CMS-10381.Appendix D Version 5010 ICD-10 Industry Readiness Assessment.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Survey	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	CMS-10381	CMS-10381.Appendix C Respondent Letters Version 5010 ICD10 Readiness Assessment	CMS-10381.Appendix C Respondent Letters Version 5010 ICD10 Readiness Assessment.pdf		Yes	No	Fillable Fileable
Form	CMS-10381	CMS-10381.Appendix D Version 5010 ICD-10 Industry Readiness Assessment	CMS-10381.Appendix D Version 5010 ICD-10 Industry Readiness Assessment.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	150	150
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.