OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Interviews

IC 199669 under ICR 201107-0938-003 · OMB 0938-1143.

Documents and Forms
Document Name
Document Type
Form
Form
Form
Form
Form
Form
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Interviews
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10360 Screener_Physicians Screener_Physicians.pdf Yes No Fillable Fileable
Form CMS-10360 ED throughput ED throughput.pdf Yes No Fillable Fileable
Form CMS-10360 HAI_HAC_MockUps HAI_HAC_MockUps.pdf Yes No Fillable Fileable
Form CMS-10360 Intensive Interview Guide_Physicians_ HAC_HAI_ED Intensive Interview Guide_Physicians_ HAC_HAI_ED_6_20.pdf Yes No Fillable Fileable
Form CMS-10360 Consent Form Consent Form.pdf Yes No Fillable Fileable

Health Health Care Services

 

18 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 18 0 0 0 0 0
Annual IC Time Burden (Hours) 4 0 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Mini Part A for Second IC_061711 Mini Part A for Second IC_061711.pdf 10/05/2011
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.