Interviews

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

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Interviews	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.