Information Collection

Interviews

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10360 Interviews	Form
CMS-10360 Screener_Physicians Screener_Physicians.pdf	Form
CMS-10360 ED throughput ED throughput.pdf	Form
CMS-10360 HAI_HAC_MockUps HAI_HAC_MockUps.pdf	Form
CMS-10360 Intensive Interview Guide_Physicians_ HAC_HAI_ED Intensive Interview Guide_Physicians_ HAC_HAI_ED_6_20.pdf	Form
CMS-10360 Consent Form Consent Form.pdf	Form
Mini Part A for Second IC_061711.pdf Mini Part A for Second IC_061711	IC Document

IC Title:

Interviews

Agency IC Tracking Number:

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	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 18

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 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

Documents for IC

table that charts IC Documents
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.