Information Collection

Consumer Research on Public Reporting of Hospital Quality Measures (IC's 3 and 4)

IC 201296 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 Consumer Research on Public Reporting of Hospital Quality Measures (IC's 3 and 4)	Form
CMS-10360 HC Formative Focus Group Mod Guide HC Formative Focus Group Mod Guide_11_15_11.pdf	Form
CMS-10360 HC Formative Testing Handout HC Formative Testing Handout 1_11_15_11.pdf	Form
CMS-10360 HC Formative Testing Handout 2 HC Formative Testing Handout 2_11_15_11.pdf	Form
CMS-10360 HC Formative Testing Handout 3_ HC Formative Testing Handout 3_11_15_11.pdf	Form
CMS-10360 Consent Form Consent Form.pdf	Form
CMS-10360 Screener_Healthcare Patient Consumers Screener_Healthcare Patient Consumers.pdf	Form
CMS-10360 Screener_Informal Family Caregivers Screener_Informal Family Caregivers.pdf	Form
Mini Part A for third IC_11_15_11.pdf Mini Part A for third IC_11_15_11	IC Document
Mini Part A for fourth IC_11_15_11.pdf Mini Part A for fourth IC_11_15_11	IC Document

IC Title:

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	HC Formative Focus Group Mod Guide	HC Formative Focus Group Mod Guide_11_15_11.pdf	Yes	No	Fillable Fileable
Form	CMS-10360	HC Formative Testing Handout	HC Formative Testing Handout 1_11_15_11.pdf	Yes	No	Fillable Fileable
Form	CMS-10360	HC Formative Testing Handout 2	HC Formative Testing Handout 2_11_15_11.pdf	Yes	No	Fillable Fileable
Form	CMS-10360	HC Formative Testing Handout 3_	HC Formative Testing Handout 3_11_15_11.pdf	Yes	No	Fillable Fileable
Form	CMS-10360	Consent Form	Consent Form.pdf	Yes	No	Fillable Fileable
Form	CMS-10360	Screener_Healthcare Patient Consumers	Screener_Healthcare Patient Consumers.pdf	Yes	No	Fillable Fileable
Form	CMS-10360	Screener_Informal Family Caregivers	Screener_Informal Family Caregivers.pdf	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

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	60	0	0	0	0	0
Annual IC Time Burden (Hours)	66	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 third IC_11_15_11	Mini Part A for third IC_11_15_11.pdf	02/17/2012
Mini Part A for fourth IC_11_15_11	Mini Part A for fourth IC_11_15_11.pdf	02/17/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.