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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.