Consumer Research on Public Reporting of Hospital Quality Measures (CMS-10360)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10360 Screener_Informal Family Caregivers	Form	New	Available
Form CMS-10360 Screener_Healthcare Patient Consumers	Form	New	Available
Form CMS-10360 Consent Form	Form	New	Available
Form CMS-10360 HC Formative Testing Handout 3_	Form	New	Available
Form CMS-10360 HC Formative Testing Handout 2	Form	New	Available
Form CMS-10360 HC Formative Testing Handout	Form	New	Available
Form CMS-10360 HC Formative Focus Group Mod Guide	Form	New	Available
Form CMS-10360 Consent Form	Form	New	Available
Form CMS-10360 Intensive Interview Guide_Physicians_ HAC_HAI_ED	Form	New	Available
Form CMS-10360 HAI_HAC_MockUps	Form	New	Available
Form CMS-10360 ED throughput	Form	New	Available
Form CMS-10360 Screener_Physicians	Form	New	Available
Form CMS-10360 ED throughput	Form	New	Available
Form CMS-10360 HAI_HAC_MockUps	Form	New	Available
Form CMS-10360 Screener_Informal Family Caregivers	Form and Instruction	New	Available
Form CMS-10360 Consent Form	Form and Instruction	New	Available
Form CMS-10360 Screener_Healthcare Patient Consumers	Form and Instruction	New	Available
CMS-10360.REVISED - Supporting Statement Part B.pdf	Supporting Statement B	Uploaded 2011-08-25	Available
CMS-10360.REVISED Supporting Statement Part A_080511.pdf	Supporting Statement A	Uploaded 2011-08-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
201296	Consumer Research on Public Reporting of Hospital Quality Measures (IC's 3 and 4)	Form	New	Screener_Informal Family Caregivers
201296	Consumer Research on Public Reporting of Hospital Quality Measures (IC's 3 and 4)	Form	New	Screener_Healthcare Patient Consumers
201296	Consumer Research on Public Reporting of Hospital Quality Measures (IC's 3 and 4)	Form	New	Consent Form
201296	Consumer Research on Public Reporting of Hospital Quality Measures (IC's 3 and 4)	Form	New	HC Formative Testing Handout 3_
201296	Consumer Research on Public Reporting of Hospital Quality Measures (IC's 3 and 4)	Form	New	HC Formative Testing Handout 2
201296	Consumer Research on Public Reporting of Hospital Quality Measures (IC's 3 and 4)	Form	New	HC Formative Testing Handout
201296	Consumer Research on Public Reporting of Hospital Quality Measures (IC's 3 and 4)	Form	New	HC Formative Focus Group Mod Guide
199669	Interviews	Form	New	Consent Form
199669	Interviews	Form	New	Intensive Interview Guide_Physicians_ HAC_HAI_ED
199669	Interviews	Form	New	HAI_HAC_MockUps
199669	Interviews	Form	New	ED throughput
199669	Interviews	Form	New	Screener_Physicians
199205	Inital Screening Round 2 (Cognitive Interviews)	Form	New	ED throughput
199205	Inital Screening Round 2 (Cognitive Interviews)	Form	New	HAI_HAC_MockUps
199205	Inital Screening Round 2 (Cognitive Interviews)	Form and Instruction	New	Screener_Informal Family Caregivers
199205	Inital Screening Round 2 (Cognitive Interviews)	Instruction	New
199205	Inital Screening Round 2 (Cognitive Interviews)	Form and Instruction	New	Consent Form
199205	Inital Screening Round 2 (Cognitive Interviews)	Form and Instruction	New	Screener_Healthcare Patient Consumers

ICR Details

OMB Control No: 0938-1143	ICR Reference No: 201107-0938-003
Status: Historical Active	Previous ICR Reference No: 201103-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Consumer Research on Public Reporting of Hospital Quality Measures (CMS-10360)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/05/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/07/2011
Terms of Clearance: Approved consistent with the understanding that individual collections (GenICs) will be submitted for review and approval prior to initiating those collections.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2014	36 Months From Approved
Responses	140	0	0
Time Burden (Hours)	187	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This PRA package covers consumer research on displays, labels, and explanatory language to insure that the website is understood by viewers in a manner consistent with CMS;s intended communication message.

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Authorizing Statute(s): PL: Pub.L. 109 - 432 109(a) Name of Law: Quality reporting for hospital services
   US Code: 42 USC 1395l(t)(17) Name of Law: Prospective payment system for hospital services
  

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 70930	11/19/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 7864	02/11/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Consumer Research on Public Reporting of Hospital Quality Measures (IC's 3 and 4)	CMS-10360, CMS-10360, CMS-10360, CMS-10360, CMS-10360, CMS-10360, CMS-10360	HC Formative Focus Group Mod Guide ,   HC Formative Testing Handout ,   HC Formative Testing Handout 2 ,   HC Formative Testing Handout 3_ ,   Consent Form ,   Screener_Healthcare Patient Consumers ,   Screener_Informal Family Caregivers
Inital Screening Round 2 (Cognitive Interviews)	CMS-10360, CMS-10360, CMS-10360, CMS-10360, CMS-10360	Screener_Healthcare Patient Consumers ,   Consent Form ,   Screener_Informal Family Caregivers ,   HAI_HAC_MockUps ,   ED throughput
Interviews	CMS-10360, CMS-10360, CMS-10360, CMS-10360, CMS-10360	Screener_Physicians ,   ED throughput ,   HAI_HAC_MockUps ,   Intensive Interview Guide_Physicians_ HAC_HAI_ED ,   Consent Form

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ICR Summary of Burden

table that charts list 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	140	0	0	140	0	0
Annual Time Burden (Hours)	187	0	0	187	0	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: This is a new information collection request.

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Annual Cost to Federal Government: $204,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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: 07/07/2011

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