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

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

Information Collection (IC) Details

View Information Collection (IC)

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

	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

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.