Nursing Home Quality Improvement Questionnaire

Documents and Forms

Document Name Document Type
Questionnaire Information Sheet [rev 02-10-2012].docx Other-Information Sheet
Followup Post Card [rev 02-10-2012].docx Other-Follow-up Postcard
CMS Invitation Lette [rev 02-10-2012].docx Other-CMS Invitation Letter
CMS-10366 Hard Copy - Nursing Home Quality Improvement Questionnai QI Questionnaire [rev 02-10-2012].docx Form and Instruction
CMS-10366 Screen Shots - Nursing Home Quality Improvement Question 5378 - Screen Shots_1-27-12.ppt Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Nursing Home Quality Improvement Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		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
Other-Information Sheet			Questionnaire Information Sheet [rev 02-10-2012].docx	No	No	Printable Only
Form and Instruction	CMS-10366	Hard Copy - Nursing Home Quality Improvement Questionnaire	QI Questionnaire [rev 02-10-2012].docx	Yes	No	Fillable Printable
Form and Instruction	CMS-10366	Screen Shots - Nursing Home Quality Improvement Questionnaire	5378 - Screen Shots_1-27-12.ppt	Yes	Yes	Fillable Printable
Other-Follow-up Postcard			Followup Post Card [rev 02-10-2012].docx	No	No	Paper Only
Other-CMS Invitation Letter			CMS Invitation Lette [rev 02-10-2012].docx	No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,200	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	2,100	2,100
Annual IC Time Burden (Hours)	693	693
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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